Professional Documents
Culture Documents
NEEDLING FOR
MANUAL THERAPISTS
of related interest
The Active Points Test
A Clinical Test for Identifying and Selecting Effective Points for Acupuncture and Related Therapies
Stefano Marcelli
ISBN 978 1 84819 233 1
eISBN 978 0 85701 207 4
DRY NEEDLING FOR
MANUAL THERAPISTS
Points, Techniques and Treatments, Including
Electroacupuncture and Advanced Tendon Techniques
Giles Gyer, Jimmy Michael and Ben Tolson
Introduction
T his book is primarily for health professionals who are treating musculoskeletal (MSK)
conditions and who wish to incorporate acupuncture into their practice. We
acknowledge that acupuncture can treat conditions other than MSK, but that is beyond the
scope of the book.
Physical therapists see many MSK problems in clinic, which makes them ideal
candidates to incorporate acupuncture into their practice. Musculoskeletal problems of
various types are often the most common reasons for patients to seek care from
acupuncturists, representing one third to one half of all visits (Sherman et al. 2005). In one
study of Chinese patients (Mao et al. 2007), patients presented with pain-related
musculoskeletal complaints such as back and neck pain (53%), arthritis (41%),
neurological complaints such as post-stroke rehabilitation and facial paralysis (23%), and
weight loss (10%). In the United Kingdom acupuncture is used in 84 per cent of chronic
pain clinics (Woollam and Jackson 1998).
Acupuncture has become more accepted by Western medicine over the last 30 years
and has seen an exponential growth in its practice worldwide (Guerreiro da Silva 2013).
As the practice of acupuncture has grown, so too has the evidence base. The advantages of
using acupuncture are well documented and include an immediate reduction in local,
referred and widespread pain, restoration of range of motion and muscle activation
patterns, and a normalization of the immediate chemical environment of active myofascial
trigger points (Dommerholt 2011). As well as these well-documented effects, acupuncture
can have simultaneous widespread effects at multiple sites.
Acupuncture as part of manual therapy is rarely a stand-alone procedure and should be
part of a broader physical therapy approach. Other approaches, including soft tissue
mobilization, manipulation, therapeutic exercise and functional retraining, should be used
in combination with acupuncture. For example, after deactivation of myofascial trigger
points, patients should be educated in appropriate self-care techniques which may include
specific stretches of the involved muscles and self-massage techniques (American
Physical Therapy Association 2013).
As the appetite for acupuncture has grown, there now exist varying standards of
training. The requirements for acupuncture training have yet to be provided and vary
considerably in practice. Broadly speaking there are two main training routes for
acupuncture: courses for lay persons and courses for medically qualified practitioners.
Those courses which are mainly for lay persons are generally very comprehensive and
will include a mixture of standard Western anatomy and pathology with a large percentage
of traditional Chinese medicine (TCM). TCM theory is extremely complex, takes a long
time to learn and includes pulse and tongue diagnosis amongst other techniques.
The courses attended by medically qualified practitioners are usually much shorter.
This is because, in the case of doctors and allied health professionals, their knowledge of
diagnosis, pathology, anatomy, physiology, microbiology and other treatment techniques
that can be used at the same time as acupuncture can be taken for granted.
White (2009, p.33) defines dry needling (also know as Western medical acupuncture)
as a therapeutic modality involving the insertion of fine needles; it is an adaptation of
Chinese acupuncture using current knowledge of anatomy, physiology and pathology, and
the principles of evidence-based medicine. Although Western medical acupuncture has
evolved from Chinese acupuncture, its practitioners no longer adhere to concepts such as
yin/yang and circulation of qi, and regard acupuncture as part of conventional medicine
rather than a complete alternative medical system. For convenience, however, the term
acupuncture will be used throughout this book.
Hong (2013, p.593) describes acupuncture as covering a diverse academic field that
spans from ancient medical history to the most advanced contemporary neurophysiology.
He continues: Acupuncture as a treatment for pain encompasses much more than simply
needling: it involves a complex interaction and context that may include empathy, touch,
intention, attention, expectation and conditioning.
The term dry needling is often used to differentiate this technique from myofascial
trigger point injections. Myofascial trigger point injections are performed with a variety of
injectables, such as: procaine, lidocaine and other local anaesthetics; isotonic saline
solutions; non-steroidal anti-inflammatories; corticosteroids; bee venom; botulinum toxin;
and serotonin antagonists (Dommerholt, del Moral and Grbli 2006).
Many acupuncturists see the use of so-called dry needling/Western medical
acupuncture as an infringement of the rights of traditional acupuncture practitioners. It is
the position of some organizations that any intervention utilizing dry needling beyond
trigger point dry needling is the practice of acupuncture, regardless of the language
utilized in describing the technique. Acupuncturists will argue that by using acupuncture
in their practice practitioners may inadvertently be affecting the whole organism without
realizing it.
Whether acupuncture falls within the confines of a single discipline or should be
incorporated into physical therapy remains a question to be answered by individuals and
the respective organizations or governing bodies. Currently in some parts of the world this
has resulted in a turf war where legislation has been passed banning the use of
acupuncture within manual or physical therapy.
At its heart, Western medical acupuncture has a scientific rationale. Acupuncture
training programmes must provide students with sufficient knowledge to communicate the
science and theories underlying acupuncture in conventional medical language.
Resistance to implementation of broad integrative clinical training has encouraged
other professions such as medicine, chiropractic and physical therapy to include
acupuncture in their scope of practice, redefined as percutaneous electrical nerve
stimulation, transcutaneous electrical nerve stimulation and dry needling (Dommerholt
2011), which explain the modality in conventional medical language (Stumpf, Kendall and
Hardy 2010).
One current argument against acupuncture being used within modern healthcare
settings in the West is that acupuncture mechanisms (how it works) cannot depend on a
philosophical or political debate that transcends clinical practice (Stumpf et al. 2010).
Only through a universal way to describe how acupuncture works, along with safe
working practices and treatment strategies, will a continued adoption of acupuncture
theory and understanding be promoted.
Stumpf et al. (2010) argue that the greatest barriers to integration, however, originate
with acupuncture training programmes based on European metaphysical ideas (Kendall
2008) which therefore do not ensure that graduates have a sufficient understanding of
quality biomedical knowledge and mainstream medicine, including primary care, or are
able to evaluate research competently (Hammerschlag 2006). Without adequate
knowledge or exposure to mainstream medicine, graduates are unprepared to (a) function
effectively in an integrative healthcare team, (b) provide competent primary care to
patients, or (c) make appropriate referrals to physicians and other mainstream providers.
The focus should be on expanding acupuncture to populations that might not
necessarily be able to access acupuncture through private practice. Just as spinal
manipulation should not be exclusive to one profession, so should the practice of
acupuncture. Our hope is that traditional acupuncturists will study the known Western
medical theories of how acupuncture works and will give a flavour of the understanding of
how traditional acupuncture works from an energetic perspective. Only by ensuring high
educational standards for training physical therapists will acupuncture be practised safely,
and this book is not intended to replace such training.
Only by integrating different modalities such as acupuncture into our practice will
patients benefit fully. The practice of integrative medicine has emerged as a potential
solution to solve complex problems seen in our patient population (Maizes, Rakel and
Niemiec 2009).
Good medicine is based on good science. It is inquiry-driven and open to new
paradigms. It is both practical and pragmatic. Although Western acupuncture has evolved
from TCM, we are not dismissing the TCM approach to acupuncture. Western medicine is
continually evolving and the explanations given are based on current evidence. As the
evidence continues to grow, we may be able to explain more of the mechanisms of
acupuncture. There is now much positive evidence to support the use of acupuncture, and
this is outlined later in the book.
The techniques in the book are the ones the authors frequently use in clinical practice.
Obviously this book is intended only as a supplement for acupuncture training. Perhaps
the use of acupuncture should be patient-centred and not driven by professional disputes.
It is our hope that by writing this book more health professionals will be able to use
acupuncture in their practice and help the many patients who are suffering in pain.
References
American Physical Therapy Association (APTA) (2013) Description of Dry Needling in Clinical Practice. Alexandria,
VA: APTA Public Policy, Practice, and Professional Affairs Unit. Available at
www.apta.org/StateIssues/DryNeedling/ClinicalPracticeResourcePaper, accessed on 15 July 2015.
Dommerholt, J. (2011) Dry needling peripheral and central considerations. Journal of Manual and Manipulative
Therapies 19, 4, 223227.
Dommerholt, J., del Moral, O.M., and Grbli, C. (2006) Trigger point dry needling. Journal of Manual & Manipulative
Therapy 14, 4, E70E87.
Guerreiro da Silva, J.B. (2013) Integrative medicine, integrative acupuncture. European Journal of Integrative
Medicine 5, 8386.
Hammerschlag, R. (2006) Evidence-based complementary and alternative medicine: back to basics. Journal of
Alternative and Complementary Medicine 12, 349350.
Hong, H. (2013) Acupuncture: Theories and Evidence. Singapore: World Scientific Publishing.
Kendall, D.E. (2008) Energy meridian misconceptions of Chinese medicine. Schweiz. Zschr. GanzheitsMedizin 20, 2,
112117.
Maizes, V., Rakel, D., and Niemiec, C.J.D. (2009) Integrative medicine and patient centred care. Explore (NY) 5, 5,
277289. Commissioned for the IOM Summit on Integrative Medicine and the Health of the Public.
Mao, J.J., Farrar, J.T., Armstrong, K., Donahue, A., Ngo, J., and Bowman, M.A. (2007) De qi: Chinese acupuncture
patients experiences and beliefs regarding acupuncture needling sensation an exploratory survey. Acupunct. Med.
25, 4, 158165.
Sherman, K.J., Cherkin, D.C., Eisenberg, D.M., et al. (2005) The practice of acupuncture: who are the providers and
what do they do? Annals of Family Medicine 3, 151158.
Stumpf, S.H., Kendall, D.E., and Hardy, M.L. (2010) Mainstreaming acupuncture: barriers and solutions. Journal of
Evidence-Based Complementary & Alternative Medicine 15, 1, 313.
White, A. (2009) Western medical acupuncture: a definition. Acupunct. Med. 27, 3335.
Woollam, C.H.M., and Jackson, A.O. (1998) Acupuncture in the management of chronic pain. Journal of Anaesthesia
53, 593595.
Chapter 2
Although Travell and Simons may have coined the term trigger points, it seems that
traditional acupuncturists have in fact been working with MTrPs from the very start, as it
has been shown that over 70 per cent of MTrPs correspond to acupuncture points when
used to treat pain (Dorsher 2009). This is why there is such similarity between traditional
and modern acupuncture techniques when treating patients who present with myofascial
pain symptoms.
Figure 3.2 Trigger point complex
Locating MTrPs
Currently a diagnosis of myofascial pain syndrome (MPS) requires the therapist to palpate
for the identification of at least one clinically relevant MTrP. However, very few
comparable, high-quality studies currently exist from which to draw firm conclusions
regarding the robustness of MTrPs examination (Myburgh et al. 2011).
Imaging such as ultrasounds and the MRIs of MTrPs have shown to have no
diagnostic relevance in the locating of active or latent MTrPs. This raises a problem for
the manual therapist: how do you locate an MTrP in order to accurately insert an
acupuncture needle into it or into the area around it? For this book we will focus on the
key skill of all therapists, which is their palpation their ability to accurately work with
the tissues of the body to identify areas of pain; and using the techniques shown within
this book, successfully treat them with medical acupuncture/dry needling. There is no X
marks the spot with MTrPs, as every patient is different, but this book and its technique
guides give the therapist a clear area of where they need to palpate in order to decide
where to place the needle.
Some clinical indications to aid therapists in the identification of MTrPs are the
following (Hong and Simons 1998):
Compression of an MTrP may elicit local and/or referred pain that is similar to a
patients usual clinical complaint (pain recognition) or may aggravate the existing
pain.
Snapping palpation (compression across the muscle fibres rapidly) may elicit a
local twitch response, which is a brisk contraction of the muscle fibres in or around
the taut band.
Restricted range of stretch, and increased sensitivity to stretch, of muscle fibres in
a taut band may cause tightness of the involved muscle.
Patients with MTrPs may have associated localized autonomic phenomena,
including vasoconstriction, pilomotor response, ptosis and hypersecretion.
Once a suspected trigger is found, pressure can be applied to determine if it is active.
Moderate but sustained palpation of an MTrP tends to accentuate the pain of an active
MTrP.
The following questions asked on application of pressure are:
1. Does this hurt?
2. Is this causing pain anywhere else?
3. Is this the pain you have been experiencing?
If the answers to these questions are all yes, this is an active myofascial trigger point.
(Refer to Chapter 8 for a more detailed insight into locating MTrPs.)
Local twitch response
An indication of locating an MTrP and also of effective needling technique, or that a
treatment will have a positive outcome, can be seen when a muscle exhibits a local twitch
response (LTR). This is a sudden and sometimes quite large contraction within that
specific muscle, and can shock both patient and practitioner. The LTR is a valuable sign
for the practitioner, as it confirms the presence of an MTrP, and studies have shown that a
transient burst of electromyographic (EMG) activity can be clearly recorded from taut
band fibres when an LTR is elicited by snapping palpation of an MTrP (Hong et al. 1997).
The LTR has a direct relationship within traditional acupuncture and the theory of deqi,
which is usually translated as to obtain or grasp the qi when needling an acupuncture
point.
LTRs are effectively a spinal cord reflex elicited by stimulating the sensitive site in an
MTrP. It has been shown to be linked with a decrease in endplate noise (Hong 1994), and
post-LTR a marked reduction in the concentration of many chemicals situated within a
muscle that can be implicated in nociception (Shah et al. 2005). These effects are likely to
lead to the reduction in the sensitivity and myofascial pain intensity.
It is also indicated that if a muscle produces a significant number of LTRs when
stimulated by an acupuncture needle, then this is due to an increased chemical irritation of
that muscles nociceptors (Hong et al. 1997). Clinical experience has shown that muscles
that have hypersensitive MTrPs will commonly produce a greater number of LTRs when
stimulated with acupuncture than areas that are not dysfunctional.
Radiculopathy and chronic pain
Radiculopathy is a condition due to a compressed nerve or nerves in the spine that can
cause pain, numbness, tingling or weakness along the course of the nerve. Radiculopathy
can occur in any part of the spine, but it is most common in the lumbar and cervical
region. The dysfunction and damage to the nerves is called a neuropathy. Radiculopathy
can be thought of as deep myofascial pain of paraspinal origin.
Dr Chan Gunn is recognized as establishing a system for treating chronic pain due to
radiculopathy. He is the founder and president of the Institute for the Study and Treatment
of Pain in Vancouver, British Columbia, Canada. Dr Gunn created the technique of
Intramuscular Stimulation (IMS), which is a diagnostic and treatment model for
myofascial pain of neuropathic origin. It works by stimulating spinal reflexes that reverse
muscle contractures (shortened muscles) through the use of fine, flexible acupuncture-
style needles.
Radiculopathy is sometimes referred to as the short muscle syndrome. With increased
muscle contraction, this affects the autonomic nervous system (ANS) by impinging nerves
at the nerve root. The nerve impingement reduces the flow of motor impulses throughout
the nerve pathway. According to Cannon and Rosenblueths Law of Denervation, a
reduction of motor impulses through a nerve pathway produces disuse sensitivity and
abnormal behaviour within the receptor organ or tissue. The Law of Denervation also
claims that the function and integrity of all innervated structures are reliant on normal
nerve functioning. Due to muscle contraction, the flow of proteins, hormones, enzymes,
neurotransmitters and electrical input along nerve fibres is blocked. The innervated
structures such as muscles, glands and neural pathways are now deprived of the essential
materials for normal functioning, resulting in abnormal sensitivity and dysfunction
(Christie 2007).
Radiculopathy also influences other tissues throughout the entire dermatome by
reducing the flow of motor impulses at the nerve root. Nerve impingement and
radiculopathy also influence distal pain by elevating acetylcholine and adrenaline levels
throughout the pathways, thereby increasing susceptibility to extremity muscular
contraction (Weiner 2001).
Continuous muscle shortening causes mechanical strain on other structures such as
tendons, ligaments and joints. Increased mechanical pressure can cause further problems
such as tendonitis, bursitis, enthesopathy thickening of tendons to their attachments (e.g.
semispinalis capitis at the occiput) degenerative arthritis and increased disc
degeneration.
Gunn often referred to paraspinal shortening as the invisible lesion, as it cannot be
seen on diagnostic imaging and requires examination by deep needling, often felt as hard
resistance when a shortened paraspinal muscle is reached (Gunn 1996).
As with all patients, treatment includes taking a detailed history (especially dermatomal
and myotomal distributions), examination, palpation and observation. Gunn emphasized
some key physical findings when examining a patient, but as radiculopathy involves the
paraspinal muscles then these must be individually palpated (Gunn 2002):
Palpation may include deep needle of the affected/suspected area for contractures.
Affected regions may have paraspinal muscles and spinous processes that are more
prominent and tender on palpation.
In the cervical spine, posterior and lateral neck creases at segmental levels indicate
involvement at that level.
Resistance to needle penetration is a sign that the level is affected. Needling may
be repeated by lifting and thrusting the needle until such resistance diminishes,
possibly over several treatments.
There may be loss of joint range or pain caused by the mechanical effects of
muscle shortening.
There may be sensory alteration: hyperalgesia increased sensitivity to pain.
There may be autonomic features.
Affected areas may feel cold due to vasoconstriction.
The affected area may exhibit excess perspiration.
There may be piloerection or goosebumps over the affected area.
There may be excess fluid in the subcutaneous tissues, as in trophedema: oedema
in hands and feet, dermatomal hair loss, inadequate or faulty nutrition of skin and
nails due to poor nerve supply.
Possible tests to confirm autonomic dysfunctions include the matchstick test, the
skin rolling test and the red line test (there are others, but these are simple and
quick to perform).
Treatment aims to reduce muscle shortening by the same mechanisms as standard
needling for myofascial pain.
Articular and joint dysfunction
Travell and Simons (1999a) categorized articular dysfunction as one of three major
categories of MSK pain, being either a primary or aggravating factor of myofascial pain.
They were in later years influenced by osteopathic and chiropractic medicine
practitioners such as Irvin Korr and Karl Lewitt helped form their later opinions on this
subject, and the second editions of their books contained updated information on the
subject.
When both an articular dysfunction and muscular problem are present, then obviously
they both need treating. The two conditions can aggravate each other. Myofascial pain
increases muscle tension and may create stresses on the joints that predispose them to
articular dysfunction. The articular dysfunction is thought to disturb the motor, sensory
and autonomic nervous system just as with myofascial pain and therefore leads to
muscular hyperactivity, which in turn causes or exacerbates myofascial pain (Clark et al.
2012).
Manipulation and mobilization techniques are thought to reduce the excitability of the
muscle spindle afferents and so reduce reflexive contractile activity. Clark et al. (2012)
propose that manipulation and mobilization work by reducing nociceptive input, which in
turn reduces excitatory input to the -motoneurons, thereby normalizing the excitability of
the stretch reflex. This decreased stretch reflex response, coupled with the reduced
nociceptive input, lessens excitatory input to the -motoneuron pool, ultimately decreasing
muscle activity. Post-treatment there is an increased range of motion at the joint, helping
to restore normal tissue functioning, which encourages normal movement.
Peripheral and central sensitization
Potentially injury-causing stimuli are detected by nociceptors, which are specialized
nerves that are found in the skin, muscle and viscera. Nociceptors respond to tissue
damage and can cause a sensation of pain when they are activated (Woolf 2010). This
process is adaptive in that pain protects us from further damage. Maladaptive pain, in
contrast, is an expression of the pathologic operation of the nervous system; it is pain as
disease, and even light touch can be considered as a noxious stimulus in extreme cases
(Woolf 2006). Both peripheral sensitization and central sensitization have common
characteristics in their response:
Thresholds are lowered so that stimuli that would normally not produce pain now
begin to do so (allodynia).
Responsiveness is increased, so that noxious stimuli produce an exaggerated and
prolonged pain (hyperalgesia).
Pain is no longer protective and serves no purpose. Changes in pain associated
with tissue damage and/or other pain triggers result in prolonged modulation of the
somatosensory system, with increased responsiveness of both peripheral and
central pain pathways. Ongoing pain can also be absent from a trigger or stimulus.
Peripheral sensitization
Woolf (2006, p.14) describes peripheral sensitization as a reduction in threshold and an
increase in responsiveness of the peripheral ends of nociceptors, the high-threshold
peripheral sensory neurons that transfer input from peripheral targets (skin, muscle, joints
and the viscera) through peripheral nerves to the central nervous system (spinal cord and
brainstem).
Tissue damage leads to a cascade of inflammatory substances being released,
including potassium ions, substance P, bradykinin and prostaglandins. These substances
may induce a sensitization of peripheral receptors with changes in the response
characteristics of primary afferent fibres. They may activate normally inactive or silent
nociceptors. Activation of latent trigger points may be part of this process (Latremoliere
and Woolf 2009).
Acute nociceptive pain is that physiological sensation of hurt that results from the
activation of nociceptive pathways by peripheral stimuli of sufficient intensity to lead to or
to threaten tissue damage (noxious stimuli). Nociception, the detection of noxious stimuli,
is a protective process that helps prevent injury by both generating a reflex withdrawal
from the stimulus and as a sensation so unpleasant that it results in complex behavioural
strategies to avoid further contact with such stimuli (Latremoliere and Woolf 2009).
Central sensitization
Woolf (2010, p.18) describes central sensitization as an increase in the excitability of
neurons within the central nervous system, so that normal inputs begin to produce
abnormal responses.
Central hypersensitivity has been documented in a number of conditions including
osteoarthritis, tension-type headache, temporomandibular joint pain, endometriosis post-
mastectomy and visceral pain. Again the pain is no longer protective and serves no
purpose.
Central sensitization is now thought to be the process behind referred pain associated
with myofascial pain. The prolonged afferent nociceptive input may induce a reversible
increase in the excitability of central sensory neurons combined with an expansion of the
receptive field, resulting in any peripheral stimulus activating a higher number of dorsal
horn neurons with an increased sensitivity to pain. Other theories propose that prolonged
muscle tension stretches specific portions of this fascia, activating pain receptors within
the tissue. This may further enhance the nociceptive input in central sensitization.
A good example is the trapezius muscle, which has low mechanical receptors and
therefore a lower pain threshold than other muscles. Repeated stimulation (such as the
upper crossed syndrome in office workers, for example) results in short-lasting pain, with
the possibility of central sensitization due to the continuous nociceptive input. This may
explain the high frequency of chronic pain at the neck and shoulder region often seen by
physical therapists.
Physiological Mechanism of
Acupuncture in Pain Control
Introduction
Acupuncture is one of the oldest forms of alternative medicine. It involves insertion of
fine needles through the skin at certain points on the body surface for a therapeutic effect.
The term acupuncture derives from two Latin roots, acus, meaning needle, and punctura,
meaning to puncture (Pyne and Shenker 2008). The practice has many different methods
and forms worldwide. In the West, two main approaches are widely used: traditional and
Western medical.
Traditional acupuncture has its origins in ancient Chinese philosophy and has been a
fundamental discipline of traditional Chinese medicine (TCM) for at least 2500 years
(VanderPloeg and Yi 2009). The earliest reference to the practice is in The Yellow
Emperors Canon of Internal Medicine, which dates back to the second or third century
BC (Bowsher 1998). Traditional acupuncture has a unique pathophysiological concept of
disease. It postulates the harmonious flowing of qi, a kind of energy, through a system of
channels (meridians), as being the basis of good health (Kawakita and Okada 2014).
Furlan et al. (2005) note that, in classical acupuncture theory, a sign of disease means that
there is an internal imbalance between the yin and yang forces, which can result in an
abnormal flow of qi within the body. The therapy focuses on restoring qi by manipulating
these two forces, needling at different depths and at strategic points on the body. However,
scientists still struggle to understand the concept of qi, since there is not enough
anatomical and histological evidence to support its existence (Ahn et al. 2008).
Dry needling, also known as Western medical acupuncture, does not involve the
concepts of qi, yin, yang or meridians, and claims to be a part of conventional medicine.
Although the technique is an adaptation of traditional acupuncture, it has its own
theoretical concepts, terminology, needling procedure and therapeutic application. White
and the Editorial Board of Acupuncture in Medicine (2009) suggest that the practice is
based on the current understanding of human anatomy, physiology and pathology, and the
principles of evidence-based medicine. Western medical acupuncture lays emphasis on the
concept of trigger points, and involves the insertion of dry needles into trigger points to
produce a clinical effect. In addition, the therapy is primarily used to alleviate
musculoskeletal pain, including myofascial pain syndromes (Cagnie et al. 2013).
However, the exact mechanism of action underlying the effects of both acupuncture
and dry needling is still not fully clarified. Many hypotheses have been proposed to
interpret the effects and mechanisms of acupuncture, but a unified theory based on
scientific evidence is lacking. This chapter briefly summarizes pain physiology (pain
pathways and modulation of pain perception), and describes the various theories of
mechanism in the context of the evidence base for acupuncture.
Physiology of pain
Pain does not mediate through a single mode of action but involves multiple cellular
mechanisms within the peripheral and central nervous systems. However, pain sensations
usually associate two types of nociceptors (specialized peripheral sensory neurons): low
threshold, that conducts action potential via myelinated A-delta fibres; and high threshold,
that conducts impulses through unmyelinated C-fibres (Patel 2010). These nociceptive
fibres terminate in the superficial dorsal horn of the spinal cord, where they form synapses
via synaptic transmission. A-delta fibres form synapses in lamina V and I, and C-fibres
connect with neurons in lamina II. A proportion of these neurons projects via nociceptive
ascending pathways (spinothalamic and spinoparabrachial pathway) to the brainstem or to
the thalamocortical system, where pain impulses are further processed and sent on to
higher levels of the brain (Schaible 2007).
Modulation of pain
Peripheral pain
Peripheral sensitization of nociceptors (including A-delta fibres and C-fibres) is
modulated by a variety of chemical mediators, such as prostaglandin, bradykinin,
serotonin, substance P, potassium, histamine, interleukin-1 beta, calcitonin gene-related
peptide (CGRP), nerve growth factor (NGF) and tumour necrosis factor (TNF). These
sensitizing agents are usually released in response to cellular damage or noxious stimuli.
In addition, local release of some of these mediators (e.g. substance P and histamine)
causes vasodilation and swelling, which in turn promote the protective mechanism of
pain (Patel 2010).
Central pain
The modulation of pain does not involve only ascending transmission of impulses from
the periphery to the cortex; it also involves descending control from certain brainstem
areas (rostral medulla, periaqueductal grey matter), which regulate the ascension of
nociceptive impulses to the brain (Ossipov 2012).
Segmental inhibition is an important mechanism that has been used to explain the
modulation of pain perception. This mechanism is a subsequent modification of gate
theory by Melzack and Wall (1967). The hypothesis proposes that the substantia
gelatinosa (SG) layer that is located in the dorsal horn of the spinal cord is opened by A-
delta and C sensory fibres and closed by A-beta fibres or by descending inhibition.
Endogenous opioids are involved in another mechanism that modulates pain
perception via the descending inhibitory pathways. Three groups of opioid peptides
(enkephalins, endorphins and dynorphins) bind to G protein-coupled receptors, mu-, delta-
and kappa-, and are defined as the endogenous opioid system (Patel 2010). These
endogenous compounds and their receptors are ubiquitously found in the areas of the
nervous systems associated with nociception. The endogenous opioid system activates
pain control circuits that descend from the brainstem to the spinal cord. The system is also
able to provide analgesic effects by directly inhibiting the ascending transmission of
impulses from the dorsal horn of the spinal cord (Millan 2002).
Besides the endogenous opioids, nerve activity in the descending pain control system
can also control the ascension of nociceptive information to the brain. Serotonin (5-HT)
and noradrenaline are the two main transmitters of this descending pathway. However,
descending dopaminergic projections may also play a significant role in pain modulation
(Benarroch 2008).
Chronic pain: central sensitization
In chronic pain conditions, the pain modulation balance is disrupted as a result of
inflammation and nerve damage (Ossipov 2012). This altered balance influences neurons
of the superficial, deep and ventral cord, causing significant changes in their response to
pain inhibition and pain facilitation. This form of neuroplasticity, a so-called central
sensitization, is often seen during cutaneous inflammation, or during inflammation in
viscera, joint and muscle (Schaible 2007).
Central sensitization mechanisms are complex; it is hypothesized that different pain
states might be involved with their specific mechanisms at least in part (Nijs, Van
Houdenhove and Oostendorp 2010). Central sensitization includes abnormal sensory
processing in the nervous system (Staud et al. 2007), enhanced sensitivity of the spinal
cord neurons, increased responses to stimuli, dysfunctional endogenous analgesia,
lowering of threshold of nociceptive neurons, expansion of receptive field sizes, altered
states of diffuse noxious inhibitory control (DNIC), and boosted activity of pain-
facilitatory pathways (Meeus and Nijs 2007).
Mechanism of acupuncture in pain control
Since the use of acupuncture first sparked in the Western world, there has been a growing
public interest about the therapy. Consequently, the need for scientific evidence for
acupunctures mechanism and effectiveness has become immense (Bowsher 1998). The
scientific community has so far proposed multiple mechanisms for the physiological
effects of acupuncture. However, most of these theories are heavily focused on
neurophysiological effects. For this reason, this chapter will primarily concentrate on the
proposed neurophysiological mechanisms of acupuncture for pain relief.
Neurophysiological mechanisms of acupuncture
Acupuncture needling has effects at multiple levels in the nervous system, including
peripheral, segmental and central neural levels.
Figure 4.1 Schematic diagram of the physiological mechanisms of acupuncture-induced analgesia
Blue arrows = activation; red arrows = inhibition. 5-HT = 5-hydroxytryptamine; DNIC = diffuse noxious inhibitory
control
Peripheral mechanisms
Acupuncture therapy has effects on local antidromic axon reflexes. Stimulation of needles
in skin and muscle activates nociceptors, including A-beta fibres, A-delta fibres and C-
fibres, which can induce an analgesic effect. Lundeberg (2013) suggests that antidromic
stimulation results in release of neuropeptides from peripheral terminals, such as CGRP
and vasoactive intestinal polypeptide (VIP), and other vasodilatory chemicals from the
tissue around the insertion, including nitrous oxide (NO) and adenosine. These chemical
mediators have either direct or indirect effects in modulating pain.
The release of CGRP has already been reported to induce skeletal muscle vasodilation
in rats (Sato et al. 2000) and to increase blood flow (Sandberg, Lindberg and Gerdle
2004). NO helps to increase local circulation, which may contribute to pain relief
(Tsuchiya et al. 2007). Adenosine has been reported to show anti-nociceptive properties
during acupuncture in mice, though it requires adenosine A1 receptor expression (Hurt
and Zylka 2012). Taken together, it can be said that local stimulation of needles may cause
vasodilation in small vessels, improve nutritive blood flow and increase anti-nociceptive
activity, factors that may be reduced in ischaemic and worsening pain conditions.
Segmental mechanisms
Acupuncture impulses ascend mainly via the spinal ventrolateral funiculus to the nervous
system. To facilitate neural mechanisms within the spinal cord, acupuncture should be
administered to tissues with innervation by the appropriate spinal cord level. Therefore,
needles should be inserted into or close by the painful body part (Bradnam and Phty
2010).
Stimulation of muscles in the segmental acupuncture points mediates primary afferent
nerve fibres (A-beta fibres, A-delta fibres and C-fibres), which terminate within the spinal
cord (Pyne and Shenker 2008). These afferent nerve fibres form synapses with inhibitory
interneurons within the dorsal horn, and influence three different sets of neurons: dorsal
horn neurons, lateral spinal cord neurons and ventral horn alpha motoneurons.
Acupunctures influence on these spinal neurons is also known as segmental effects
(Bradnam and Phty 2010).
Inhibition of nociceptive input
Stimulation of dorsal horn neurons facilitates the A-delta and A-beta fibre-mediated gate
control mechanism, which results in inhibition of the nociceptive pathway at the dorsal
horn by activating the descending pain inhibitory systems (Staud and Price 2006). In
support of this theory, Cagnie et al. (2013), in their review, suggested that rapid
stimulation of dry needles could activate both the large A-beta fibres and A-delta fibres,
which could project afferent impulses through the dorsolateral tracts of the spinal cord to
the central nervous system. This can more potently influence the supraspinal and
brainstem areas associated with pain modulation. Furthermore, A-beta fibres have long
been presumed to activate the gating mechanism (see Modulation of central pain,
above); however, many studies have supported the hypothesis (Dickenson 2002).
In addition, Chu and Schwartz (2002) stated that, when a needle is speedily inserted
into a trigger point, the local twitch responses induced result in a large afferent nerve fibre
proprioceptive input into the spinal cord. This could have a central effect on the pain gate
in the spinal cord, blocking the intra-dorsal horn passage of noxious information produced
in the trigger points nociceptors. Taken together, it can be said that activation of A-beta
fibres can also project a segmental inhibition by interrupting A-delta fibres and C-fibres
from forming synapses with the neural cells in the dorsal horn.
Alterations in sympathetic outflow
Neurons in the lateral spinal cord can alter the sympathetic outflow to tissues, as they
contain the cell bodies of the autonomic nervous system efferent fibres. Stimulation of
these neurons by segmental acupuncture at the appropriate spinal level has been presumed
to produce strong analgesic effects by altering the sympathetic outflow to tissues.
Lundeberg (2013) suggests that using segmental acupuncture points connected to a
specific organ may alter its function by modulating both sympathetic and parasympathetic
activity. However, effects on the sympathetic nervous system are intensity-dependent, and
can be manipulated depending on the strength of needle stimulation. High-intensity
needling increases sympathetic outflow and blood flow to target muscles, followed by a
longer-term decrease in outflow (Noguchi et al. 1999). Low-intensity or non-painful input
reduces sympathetic outflow from the segment (Sato, Sato and Schmidt 1997).
Changes in motor output
The release of endogenous opioids has been the most well-known mechanism of
acupuncture analgesia. The first proposal of an opioidergic mechanism was based on a
groundbreaking finding that naloxone is able to block or reverse the analgesic effects of
acupuncture (Pomeranz and Chiu 1976). However, the theory came to other researchers
attention when Fine, Milano and Hare (1988) reported that the pain relief activity of
bupivacaine, a local anaesthetic drug of the amino amide group, was also reversed by
naloxone. This new finding, in turn, provided strong evidence to support acupunctures
opioidergic mechanisms.
Since the proposal of the hypothesis, many studies have further supported opioidergic
mechanisms of acupuncture. In addition, it is now disclosed that different kinds of
endogenous opioid peptides, including -endorphin, endomorphin, enkephalin and
dynorphin, play key roles in acupuncture-induced analgesia (Chou, Kao and Lin 2012).
Serotonergic and noradrenergic descending inhibitory pathway theories
Serotonin (5-HT, 5-hydroxytryptamine) and noradrenaline have long been thought to play
very important roles in acupuncture analgesia. It is hypothesized that stimulation of A-
delta sensory fibres from needling may facilitate the serotonergic and noradrenergic
systems. Chou et al. (2012) and Leung (2012), in their reviews, highlighted a number of
studies that supported the theory for electroacupuncture to date. However, no specific
experimental or clinical studies were found that support the proposed serotonergic and
noradrenergic mechanisms for traditional acupuncture and dry needling (Cagnie et al.
2013).
Diffuse noxious inhibitory control theory
DNIC is the phenomenon where nociceptive inputs from sensory afferents are strongly
blocked when a noxious stimulus affects the body, distant from their excitatory
sympathetic fields. DNIC functions via opioidergic descending systems from the caudal
medulla and requires activation of thin afferent fibres (A-delta fibres and C-fibres). These
fibres travel down to all levels of the spinal cord to induce a potential inhibitory effect
(Leung 2012).
DNIC system stimulation is another theory for acupuncture analgesia that is
hypothesized to explain the immediate suppression of pain. The theory also proposes that
DNIC may be the mechanism behind analgesic effects when needles of acupuncture are
inserted at points distant from the actual pain source extra-segmental needling (Pyne and
Shenker 2008). In support of this theory, Bing, Villanueva and Bars (1991), based on
studies in rat medulla, suggested that manual needling to the Zusanli (ST-36) could
produce DNIC-like suppression and that the naloxone partially antagonized the pain relief
effect. However, two clinical studies done on both healthy and whiplash patients have
recently reported that DNIC on immediate summation of pressure pain did not show any
noteworthy response to manual needling (Schliessbach et al. 2012; Tobbackx et al. 2012).
Mechanisms not yet known
Segmental dysfunction
Segmental dysfunction has been understood as mechanical problems of the components
linked to the somatic system: skeletal, arthrodial and myofascial structures, and related
vascular, lymphatic and neural elements. Proper functioning of each of these links is
related to the normal motion of the entire spine.
Segmental dysfunction is not a disease or a pain syndrome; however, the majority of
patients with the problem may complain of pain. Watkin (1999) suggests that segmental
dysfunction is a problem in the function of a spinal segment, which may cause symptoms
without necessarily being caused by physical pathology. The concept has been found
useful for patients who complain of pain but have normal radiological and laboratory
investigations.
The sympathetic nervous system (SNS) appears to strongly mediate the signs of
segmental dysfunction. Since segmental acupuncture at the appropriate spinal level can
influence the SNS, it has been presumed as a potential intervention to treat segmental
dysfunction. In addition, as acupuncture lays emphasis on discovering and treating the
symptomatic segmental spinal level, treating segmentally can be of diagnostic value in
discovering the correct dysfunctional segment. However, there seems to have been no
investigation on how acupuncture affects the measurable components of the dysfunctional
segment. Therefore, it has been identified as a rich field for research (Watkin 1999).
Peripheral neuropathy (Gunns theories)
Gunn (1989) proposed a peripheral neuropathy model to explain myofascial pain in a new
way. This model suggests that, although pain may be linked to the signals of tissue injury,
pain does not always signal injury, nor does injury always generate pain: pain perception
can arise from non-noxious input. The model blames neuropathic pain on abnormal
function in nerves. It also suggests that pain can become persistent due to ongoing
nociception or inflammation, psychologic factors (such as a somatization disorder,
depression or operant learning processes) and abnormal function in the nervous system.
Gunn defined peripheral neuropathy as a disease that results from disturbed or
abnormal function in the peripheral nervous system with or without an altered structure.
He suggested that a neuropathic nerve could deceptively appear normal: it might still
conduct nerve impulses, synthesize and release transmitted substances and evoke action
potentials and muscle contraction (Gunn 1990). In addition, Gunn (2003) also denoted the
manifestations of neuropathy as radiculopathy (i.e. neuropathy at the nerve root), since
they are usually found in both dorsal and ventral rami of the segmental nerve.
Gunns model of neuropathic pain is founded upon Cannon and Rosenblueths (1949,
p.5) Law of Denervation, which states that when a unit is destroyed in a series of efferent
neurons, an increased irritability to chemical agents develops in the isolated structure or
structures, the effect being maximal in the part directly denervated.
Based on this law, Gunn suggested that the goal in treating myofascial pain should be
to desensitize super-sensitivity by restoring the flow of impulses in a peripheral nerve. But
chronic myofascial pain does not usually occur without contractures and muscle
shortening; therefore, their release was suggested to restore joint range and relieve pain.
However, contracture-release requires a definitive procedure, such as physical stimulus, to
decompress the nerve root and thereby break the vicious circle, as it does not release with
conventional treatment.
Gunn claimed that accurate and repeated needling is the only effective way to release
the contracture and disperse any dense, fibrotic tissue entrapping a nerve root. He
introduced Intramuscular Stimulation (IMS), an alternative system of diagnosis and dry
needling based on a radiculopathy model, for the management of chronic myofascial pain
(Gunn 2003).
Clinical reasoning approach: the layering method
The layering method is a technique for acupuncture treatment to choose appropriate points
and stimulation parameters in order to administer an optimum intervention. This method
contains a series of questions that the clinicians ask themselves for clinical reasoning, so
that they can evaluate the highly desired acupuncture effects for the patient (Bradnam and
Phty 2010). Some of the common suggestions for the clinical reasoning questions include
the following:
If restoration of injured tissues or treatment of scar tissue is the main concern of
the therapist, then eliciting local effects by acupuncture to encourage blood flow to
tissues is useful. Local effects can be enhanced by using local acupuncture points,
or simply by placing the needle directly into the injured tissue (Lundeberg 2013).
If segmental effects are desired, then points chosen for local effects can be used,
because these points can concurrently induce segmental effects. However, in the
early stages of tissue damage when the rise in blood flow is significantly
damaging, these points should be avoided. Bradnam (2007) suggests that, in this
case, any points that share an innervation via that spinal segment can be chosen
(muscles, skin periosteum).
If there is a slow-healing or chronic injury or a condition has a sympathetic
component, then specific manipulation of the SNS can be used to alter sympathetic
outflow to tissues (Bradnam 2003). Needling at the segmental points related to the
target tissue, or needling a point in the periphery sharing the segment, can be used
to stimulate the SNS (Bekkering and van Bussel 1998).
Are the therapeutic effects of acupuncture purely placebo analgesia?
In recent years, there have been many debates about whether the recorded physiological
effects of acupuncture are purely placebo or more than a placebo. Opponents of needling
therapies often argue that the mechanism behind acupunctures success is nothing else but
placebo effects, since studies suggest that expectations can actually modulate the
perception of pain and involve subcortical and opioid-sensitive brain areas (Lyby,
Aslaksen and Flaten 1999). They also add that placebo can activate the endogenous opioid
system, as naloxone seems to reverse expectancy placebo (Amanzio and Benedetti 1999),
like acupuncture-induced surges in pain threshold. However, a thorough observation of
multiple studies suggests that acupuncture is more than a placebo and may have a more
specific analgesic effect.
Acupunctures delayed onset of action (by 12 hours) clearly shows that its therapeutic
effects are not similar to the characteristics of placebo analgesia, which is typically
immediate and short-lived (Price et al. 1984). In addition, once acupuncture therapy is
ceased, its analgesic effects may last for up to 23 weeks, which is also very unusual for
placebo (VanderPloeg and Yi 2009). Furthermore, several studies (Facco et al. 2008;
Mayer, Price and Rafii 1977; White et al. 2007) have suggested significantly higher
clinical effects of acupuncture compared with placebo.
Acupuncture-specific responses are also reported in neuroimaging studies. Multiple
fMRI studies have suggested that stimulation of needles at Zusanli (ST-36), Yanlingquan
(GB-34) or Hegu (LI-4) points may modulate CNS activities, including the activities of
cerebral limbic or paralimbic and subcortical structures (Li et al. 2000; Wu et al. 1999;
Yan et al. 2005). Pariente et al. (2005), using PET scanning, found that the ipsilateral
insula was activated to a greater extent during true acupuncture than during the placebo
sham acupuncture. Taken together, these findings clearly suggest that real acupuncture is
not just a placebo but has a more specific physiological effect. However, more work is
needed to explain the definite neurophysiologic alterations from acupuncture needling.
Conclusion
After reviewing the current findings in scientific research, it can be concluded that the
physiological mechanisms and effects of traditional and Western medical acupuncture are
overly complex and involve peripheral, segmental and central neural networks. However,
more insights into acupunctures pathophysiological mechanisms are needed, since there
are other mechanisms of acupuncture on the CNS which need to be fully explored. Studies
researching acupunctures neurophysiological and biomechanical mechanisms should,
therefore, develop and apply adequate models of chronic pain to better explore the
mechanisms. At the same time, clinical trials on acupuncture should have adequate sample
sizes, use an effective needling technique, and have both a long-term and short-term
follow-up to support its true clinical significance.
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Chapter 5
Item Detail
1. Acupuncture rationale 1a) Style of acupuncture (traditional Chinese medicine, Japanese, Korean, Western
(Explanations and examples) medical, Five Element, ear acupuncture, etc.)
2. Details of needling 2a) Number of needle insertions per subject per session (mean and range where
(Explanations and examples) relevant)
4. Other components of treatment 4a) Details of other interventions administered to the acupuncture group (e.g.
(Explanations and examples) moxibustion, cupping, herbs, exercises, lifestyle advice)
6. Control or comparator 6a) Rationale for the control or comparator in the context of the research question,
interventions with sources that justify this choice
(Explanations and examples)
6b) Precise description of the control or comparator. If sham acupuncture or any
other type of acupuncture-like control is used, provide details as for items 1 to 3
above
Table 7.1 Findings of systematic reviews and meta-analyses of acupuncture for conditions related to pain
Post- Sun et al. 15 Nine studies reported a statistically significant Peri-operative acupuncture
operative (2008) reduction in pain scores compared with control may be a useful adjunct
pain groups, one study was excluded from the analysis for post-operative
and three studies did not report data on pain scores. analgesia.
Acute dental Ernst and 16 Twelve trials reported that acupuncture was more Acupuncture can reduce
pain Pittler effective than controls, but four trials suggested the dental pain.
(1998) contrary.
Low back Furlan et 35 The average improvement in pain with acupuncture Acupuncture is more
pain al. (2005) for acute low back pain was 52% (based on two effective than sham or no
studies), 32% for chronic (16 studies) and 51% for treatment; appears to be
unknown or mixed durations of pain (eight studies). useful adjunct to other
therapies for chronic low
back pain.
Myofascial Tough and 7 Six studies reported statistically superior outcomes Acupuncture is superior to
trigger point White compared to placebo. placebo; is likely to be the
(MTrP) pain (2011) most effective approach
for MTrP-derived pain.
Fibromyalgia Berman et 3 All the trials found statistically significant positive Acupuncture may be
al. (1999) findings compared with control groups. effective for fibromyalgia;
more high-quality trials
are needed.
Osteoarthritis Ezzo et al. 7 Two trials compared acupuncture with wait list: both Acupuncture may play a
of the knee (2001) found statistically significant results; three trials role in the treatment of
compared acupuncture to placebo: two found knee osteoarthritis; more
statistically significant outcomes; two trials well-designed trials are
compared acupuncture to physical therapy: both necessary to reach a
reported no significant finding for acupuncture. conclusive decision.
Palpation
I t is assumed that the reader has some experience of palpation. However, it is a subject
always worth revisiting as there is no limit to how much you can improve your
technique (Denmei 2003). Palpation is the practice of informed touch. It is both an art and
science and requires skills, dedication and practice. It needs to be performed with
sensitivity, as we are palpating human beings who are often in pain and discomfort and
who are seeking professional help. There is no substitute for good palpation, and with
practice one can have confidence in knowing what is normal and abnormal. With time one
can develop reliable, rapid, responsive instruments.
The muscular system can be evaluated in a number of ways, including strength,
movement, appearance, tone, firing patterns, and active and passive movements. Palpation
is just one of those means of investigation, but is an important one. Czechoslovakian Dr
Vladimir Janda emphasized the fact that time spent in assessment will save time in
treatment (Janda 2012).
There has always been doubt raised over the reliability of palpation of musculoskeletal
disorders; however, in daily practice it is used frequently. Finando and Finando (2005)
describe palpation as a skill that is at the very core of manual therapy and helps us
evaluate our patients and perhaps how patients evaluate the practitioner, as it is through
the first touch that the patient discovers much about the practitioner and is part of the
dialogue between patient and practitioner.
Radiography, MRI and other diagnostic tests and their interpretation are also part
science and part art, so are no different from palpation, interpretation and reliability in
some respects. However, whilst it is routine and best practice to send patients for further
diagnostic scans, there is debate as to how informative the results are, as up to 60 per cent
of women and 80 per cent of men at age 50 show evidence of degenerative changes of the
spinal column, while by the age of 70 the figure is 95 per cent for both sexes.
When palpating, a detailed knowledge of anatomy, attachments, insertions and muscle
action are all essential components. Generally speaking, healthy muscle tissue will feel
soft, pliable and alive. Every muscle will have its own particular characteristics in terms of
fibre orientation, action and typical areas where it will develop dysfunction. Every body
tells a storylet the body speak to you.
What we decide about the information from our palpation essentially has to be
assimilated within each practitioners professional context, whether osteopathy,
chiropractic, physiotherapy, acupuncture or other profession, and used accordingly. Each
practitioner has to use their own subjective description of what they are feeling and put
that into a diagnostic framework. Dr Felix Mann, a well-known pioneer of Western
acupuncture in the UK, commented that there is little if any part of the body surface that
has not been designated to some therapeutic system (Mann 2000). This can be clearly seen
within traditional Chinese medicine (TCM) with the 12 main channels, eight extra
channels, extra points, scalp points and auricular points.
Palpation skills are fundamental as a diagnostic aid because they affect clinical results.
A palpatory examination is essential when continuing to treat a patient because it confirms
if any change has taken place which will change or reinforce our treatment strategies and
protocols. However, palpation is a complex task that requires the right combination of
knowledge, skills and attitude and can only be learnt by palpating on a regular basis.
A degree of sensitivity must be applied when palpating, as some patients have little or
no body awareness and may have different cultural connotations. While the palpatory
process will be second nature to the experienced practitioner, it may be a strange or
unfamiliar process for the patient. This is in direct contrast to the more body-aware
athletes or those who partake in regular physical activity who can often participate in the
process and guide the practitioner.
MacPherson (1994, p.7) describes palpation as having an educational role whereby
the patient learns to give weight and value to the subjective sensations of their body.
Sometimes palpation can validate what the patient is experiencing; or reveal to them that a
distal unknown part of their body is capable of producing pain, as in cases of referred
pain. Sometimes a technique can be performed for a few seconds and the same area re-
palpated to detect for change to confirm to both patient and practitioner that a change has
been made.
Technique
In discussing palpation, Legge (2011, p.36) states that each practitioner should develop
their own way of developing a routine of examining each patient. Having a consistent
structured approach for examination of each section is crucial to clinical success. Aubin,
Gagnon and Morin (2014) created the PALPATE acronym as a means of teaching
osteopathy students the art of palpation. The results of this meant the students seemed
more confident and, as predicted, demanded less external validation in technique classes.
They understood more clearly the stakes of palpation and the importance of repeating each
technical movement (Aubin et al. 2014, p.8).
The seven steps are as follows:
1. Position comfortable positioning of the clinician
2. Anatomy 3D anatomic visualization
3. Level depth of tissue contact
4. Purpose clear identification of intention
5. Ascertain initiate motion with a relative point of reference
6. Tweaking fine-tuning of the five previous steps and perceptual exploration
7. Evaluate or normalize apply technique parameters.
Another useful acronym commonly used is STAR or TART, developed by Dowling
(1998), an osteopath who used the acronym for the findings of dysfunction in assessment
and palpation:
Sensitivity
Tissue texture changes
Asymmetry
Range of motion reduced
or:
Tenderness
Asymmetry
Restricted motion
Tissue texture changes.
The process of palpation can be further categorized into static and motion palpation. In
static palpation the patient is prone or supine and the practitioner will palpate the area or
areas and observe what he/she feels. This is commonly used to detect areas of pain and
tenderness. Motion palpation can be divided into active (non-practitioner-assisted) and
passive (practitioner-assisted) and is used to assess functional movement that is normal for
the patient being examined.
Palpation when searching for acupuncture points sometimes requires a very light touch
and a focusing of your palpation skills. It is useful to alternate between the methods
described for palpating trigger points, from a strong firm pressure to a lighter touch, as a
lighter touch can be just as effective as a palpation tool. Denmei (2003) describes a
number of methods for locating acupuncture points. These are areas and points with
abnormal temperature, depressed points, points with abnormal moisture, and points with a
feeling of softness like pressing on a balloon. Denmei further discusses other palpation
techniques for locating points on the abdomen: using a stroking technique and pinching to
detect changes in tissue and any abnormalities. Different areas vary, so a variety of
palpation techniques should be employed to improve reliability.
Applicators
When considering the choice of applicators available, Neil-Asher (2014) describes using a
number of different areas when palpating for trigger points. These are finger pads, flat
finger, pincer palpation, flat hand, thenar eminence and elbow.
It must be stressed that not all areas of the body have equal amounts of touch
receptors. The fingertips and tongue may have as many as 100 per cm2; the back of the
hand fewer than 10 per cm2. Therefore, when palpating, the fingertips and thumb are the
most sensitive areas, but with time one can develop sensitivity using different applicators.
Depth of pressure
Any pressure hard enough will result in pain, and is not very reliable as a clinical tool.
Therefore vary the pressure, starting from light and increasing to moderate to deep. Light
touch will include detections of change of skin temperature, moisture and elasticity. If you
consider that soft tissue dysfunction can occur at any depth, then using a variable depth to
probe the different layers is important.
Practitioner positioning is a key factor when palpating. Correct practitioner positioning
can deliver varying forces and directions to the patient whilst maintaining practitioner
comfort and awareness. Having the table set to a good working height should allow for the
transference of bodyweight to the patient whilst being relaxed and not having hunched
shoulders. Having the table/plinth too high usually results in increased muscular force
being used to palpate deeper structures. This will result in loss of proprioception,
increased strain and fatigue in the practitioner, and unnecessary force and pressure on the
patient.
Structure and function
Structure and function are reciprocally interrelated. Functional demands involve demands
from the structure to meet those needs.
To treat or not to treat that is the question!
A tight hamstring may be stabilizing a dysfunctional sacroiliac joint, or it may be part
of a larger clinical picture, such as Dr Vladimir Jandas lower-crossed syndrome (which is
a particular pattern of muscular imbalance in the lower body).
Trigger points may be acting as stabilizing functions in hypermobile patients. Chaitow
et al. (2010) hypothesize that trigger points have a functional purpose to offer an
efficient means of short-term stability in an otherwise unstable environment.
Faulty posture and its overload of the muscular system is now an extremely important
factor in the patient population seen by manual therapists. Correcting faulty posture will
often be a key part of the treatment strategy to relieve pain, highlighting the link between
structure and function.
In reference to trigger points and the possible adaptations that can occur, Travell and
Simons (1999) noted that trigger points in one area can affect the motor activity of other
muscles. In one example it was seen that a trigger point in a right soleus caused a spasm in
the right lumbar paraspinal muscles. Similarly, trigger points in the quadratus lumborum
can cause inhibition of the ipsilateral gluteal muscles. No injury should be seen in
isolation, and a full biomechanical assessment should always be performed.
Travell and Simons (1999), in their seminal work on trigger points, emphasized the
importance of treating articular dysfunctions. A facilitated spinal segment can cause an
increase in paraspinal activity. A trigger point and its associated increased tension can
cause articular dysfunction, whilst simultaneously a facilitated spinal segment can
contribute to trigger point activation via changes in the motor, sensory and autonomic
components of the nervous system. This effect can occur over several segments, leading to
activation of further trigger points along the spine. It is important to have these concepts in
mind when palpating and assessing. Treatment should therefore address both the trigger
points and articular dysfunction.
A radiculopathy model
Gunns (1997a) theory states that chronic pain can occur in the event of:
ongoing nociception or inflammation
psychological factors such as a somatization disorder, depression or operant
learning processes
abnormal function in the nervous system.
According to Gunn, the myofascial pain syndrome can be the result of peripheral
neuropathy, nerve root impingement and paraspinal muscle spasm. The spinal nerve
dysfunction leads to an increase in muscle tone of the paraspinal muscles such as
multifidi, leading to disc compression and irritation. This further irritates the neuropathy
and a vicious cycle is created, one perpetuating the other. Which came first is a matter of
discussion and debate. Gunn considers spondylosis, or bony/spur formation, as the most
likely cause of nerve dysfunction. Gunns treatment is aimed at the musculo-tendinous
junctions or the location of the muscle motor points.
Gunn also considered that some of the deeper muscles of the back (for example,
semispinalis thoracis, multifidus, rotatores muscles) must be palpated by needling, as they
are beyond palpation by hand. He considered that only then can the affected muscle be
identified and treated. Gunn (1997b, p.5) wisely uses the needle as a powerful diagnostic
and treatment tool. Gunn, when needling, is guided by the deqi response and tissue
feedback. For example, Gunn describes the needling of fibrotic tissue as often being
mistaken for bone and requiring a sustained force to penetrate. Needling should be an
extension of palpation, as one can have a sense of the tissues being needled, tissue
resistance, ease of needling, where the tip of the needle is, and the underlying structures
and tissues being affected.
Chapmans points, TCM alarm and associated points
Osteopath Dr Frank Chapman in the 1930s showed a correlation between tender areas on
palpation and associated visceral involvement. These tender areas are believed to be active
neurolymphatic reflexes that can usually be palpated. The tenderness is usually in direct
ratio to the chronicity and severity of the condition. For example, a group of reflexes are
found between the spinous processes, where upon palpation the area feels spongy and has
a close correspondence with the acupuncture points in the same location.
In TCM the same diagnostic reflexes exist where certain acupuncture points become
sensitive to pressure when the meridian or organ to which they are reflexively connected is
distressed. In a study by Kim (2007), an analysis of the similarity of locations between
Chapmans neurolympathic reflex points and acupuncture points, the two systems
identified anatomically 71.1 per cent of the anterior points and 93.1 per cent of the
posterior points. When considering what one is feeling, a visceral reflex activity must be
considered along with a musculoskeletal one.
Fascial considerations
Acupuncture meridians are believed to form a network throughout the body, connecting
peripheral tissues to each other and to central viscera. Disruption of the meridian channel
network is believed to be associated with disease, and needling of acupuncture points is
thought to be a way to access and influence this system (Cheng 1987). Several authors
have noted that interstitial connective tissue also fits this description, and conclusions have
been drawn that acupuncture meridians tend to be located along fascial planes between
muscles (Cheng 1987; Langevin and Jason 2002).
Thomas Myers, founder of Structural Integration (which has built upon the work of
Ida Rolf), coined the term myofascial meridians, which are defined as anatomical lines
that transmit strain and movement through the bodys myofascia. These myofascial
meridians were discovered through his analyses of human cadaver dissections that
examined the interconnections of the bodys fascia, tendons and ligaments, which form
anatomical grids postulated as integral to the support and function of the locomotor system
(Dorsher 2009). Myers (2009, p.237) himself comments on the close relationship between
acupuncture meridians and the myofascial meridians: the close relationship between
the two is inescapable, especially in light of recent research on and through the
extracellular matrix.
Broadly speaking, myofascial meridians present a mechanical stress model of fascia
compared with the TCM model, which is visceral somatic. Trigger points tend to occur
along myofascial meridians due to the way the body dissipates force along the course of
these linkages (Neil-Asher 2014). Sharkey (2008) suggested a number of kinetic chains
describing how the body moves by transmission of forces along these chains. This
provides a more global view on movement. Janda (2012) always stated that compensations
within chains create more dysfunctional movement, which is frequently seen in practice.
Treatment may be over several sessions until the primary dysfunction is revealed and
resolved. When considering the evidence, the suggested optimal treatment of any
presenting MSK disorder must include the assessment and treatment of these myofascial
meridians along with localized treatment for a truly successful outcome. Knowledge of the
acupuncture meridians or myofascial meridians will enhance treatment outcome. Tender
sites are almost consistently found in muscle at motor points or at muscletendon
junctions (Gunn and Milbrandt 1976).
When considering where to needle, Langevin and Jason (2002, p.7) propose an
enhanced effect at traditional points: the enhanced needle grasp response at
acupuncture points may be due to the needle coming into contact with more connective
tissue (subcutaneous plus deeper fascia) at those points.
Needle grasp is not unique to acupuncture points but rather is enhanced at those points,
so some knowledge of traditional acupuncture points may be useful. Palpate around the
area of these points for the most effective treatment, using the palpation techniques as
described earlier. Whilst needling, anywhere will have some effect, but needling at
traditional points will have a better outcome due to the convergence of connective tissue
that permeates the entire body (Langevin and Jason 2002).
If you consider just a handful of points such as Gallbladder 34, Triple Burner 15 and
Bladder 10, these all have multiple muscles overlaying these points and have converging
layers of fascia.
The fascia yet may reveal more secrets about visceral dysfunction. The technique of
channel palpation involves palpating along the pathways of the 12 main acupuncture
channels as an aid to diagnosis in TCM. Diagnostic palpation is particularly useful in the
areas below the elbows and knees. Channel palpation provides a reliable, verifiable and
relatively measurable way for practitioners to confirm diagnostic hypotheses derived from
more mainstream Chinese medical approaches. Furthermore, because channel palpation
provides significant information about the state of organ function, it can help focus
diagnosis and treatment (Wang and Robertson 2007). It is beyond the scope of this book to
describe fully the palpation process, but rather just to illustrate interpretations of fascia
within TCM.
Conclusion
There are clearly many different ways of palpating, and even more different
interpretations and possible treatments. This chapter is by no means the definitive guide
on the subject, but we hope that it has encouraged the reader to engage and explore the
process of palpation. As Denmei (2003, p.23) eloquently states: Satisfactory results can
only be obtained when the four steps of diagnosis, point selection, point location and
needles insertion all come together.
References
Aubin, A., Gagnon, K., and Morin, C. (2014) A proposal to improve palpation skills. International Journal of
Osteopathic Medicine 17, 6672.
Chaitow, L., Chaitow, S., Chemlik, S., Lowe, W., Myers, T., and Seffinger, M. (2010) Palpation and Assessment Skills:
Assessment through Touch (third edition). Edinburgh: Churchill Livingstone.
Cheng, X. (1987) Chinese Acupuncture and Moxibustion. Beijing: Foreign Language Press.
Denmei, S. (2003) Finding Effective Acupuncture Points. Seattle, WA: Eastland Press.
Dorsher, P. (2009) Myofascial meridians as anatomical evidence of acupuncture channels. Medical Acupuncture 21, 2.
Dowling, D. (1998) S.T.A.R.: a more viable alternative description system for somatic dysfunction. AAO Journal 8, 2,
3437.
Finando, S., and Finando, D. (2005) Trigger Point Therapy for Myofascial Pain: The Practice of Informed Touch.
Rochester, VT: Healing Arts Press.
Gunn, C.C. (1997a) Myofascial pain, a radiculopathy model. Journal of Musculoskeletal Pain 5, 4, 119134.
Gunn, C.C. (1997b) Intramuscular Stimulation (IMS) The Technique. iSTOP Institute for the Study and Treatment of
Pain. Available at www.istop.org/papers/imspaper.pdf, accessed on 23 July 2015.
Gunn, C.C., and Milbrandt, W.E. (1976) Tenderness at motor points: a diagnostic and prognostic aid for low-back
injury. J. Bone Joint Surg. Am. 58, 6, 815825.
Janda, V. (2012) The Janda Approach to Chronic Syndromes. Available at
www.jandaapproach.com/2012/11/02/timeless-vladimir-janda-quotes-and-concepts, accessed on 17 August 2015.
Kim, O. (2007) Comparative Analysis of the Topographical Locations of Acupuncture Points and Chapmans Reflex
Points. Unpublished thesis submitted in partial fulfilment of the degree of Master of Osteopathy, Unitec New
Zealand, New Zealand. Available at http://unitec.researchbank.ac.nz/handle/10652/1347, accessed on 23 July 2015.
Langevin, H., and Jason, A. (2002) Relationship of acupuncture points and meridians to connective tissue planes. The
Anatomical Record 269, 6, 257265.
Legge, D. (2011) Close to the Bone: The Treatment of Painful Musculoskeletal Disorders with Acupuncture and Other
Forms of Chinese Medicine (third edition). Taos, NM: Redwing Book Co.
MacPherson, H. (1994) Body palpation and diagnosis. Journal of Chinese Medicine 44, 512.
Mann, F. (2000) Reinventing Acupuncture: A New Concept of Ancient Medicine (second edition). Oxford: Butterworth-
Heinemann.
Myers, T. (2009) Anatomy Trains (second edition). Edinburgh: Churchill Livingstone.
Neil-Asher, S. (2014) The Concise Book of Trigger Points (third edition). Chichester: Lotus Publishing.
Sharkey, J. (2008) The Concise Book of Neuromuscular Therapy: A Trigger Point Manual. Chichester: Lotus Publishing.
Travell, J.G., and Simons, D.G. (1999) Myofascial Pain and Dysfunction: Upper Half of Body Volume 1: The Trigger
Point Manual (second edition). Baltimore: Lippincott Williams & Wilkins.
Wang, J.-Y., and Robertson, J. (2007) Channel palpation. Journal of Chinese Medicine 83, 1824.
Chapter 9
Deqi
T here is a distinct cross-over between dry needling/Western acupuncture and
traditional acupuncture techniques, so it is vitally important that we understand the
original theories and how they relate to current modern thinking.
Our current concept of the mechanisms of action within dry needling is that in one
aspect we are treating myofascial pain through the identification and needling of
myofascial trigger points (MTrPs), and as an effect of acupuncture on a muscle we can
evoke a local twitch response (LTR) a spasm or contraction within the muscle and this
stimulates a pain-relieving effect among other responses.
This LTR has been referred to for centuries within traditional acupuncture techniques
from all over the world. It is known as deqi, and is a fundamental aspect of traditional
acupuncture treatments.
Deqi is usually translated as to obtain or grasp the qi when needling an acupuncture
point. The deqi sensation is felt by both practitioner and patient. Langevin, Churchill and
Cipolla (2001) define deqi as a sensory component perceived by the patient together with
a biomechanical component perceived by the practitioner.
There is a long-held belief that deqi is important in order to achieve positive
therapeutic outcomes in acupuncture. However, it is unclear whether this is actually the
case, as some acupuncture styles pay no clinical importance to it.
In one study of 574 members of the British Acupuncture Council (the primary
organization of traditional acupuncturists in the UK), 87 per cent aimed to attain deqi
(MacPherson et al. 2001). In a study of Chinese acupuncture patients, the majority of
patients endorsed the importance of deqi in acupuncture therapy and 68 per cent further
believed that the stronger the deqi sensation, the more effective the acupuncture treatment
(Mao et al. 2007). Eighty-nine per cent of subjects reported that the needling sensation
travelled away from the puncturing points or travelled among the needling points
(MacPherson et al. 2001). Some authors suggest that Chinese-trained practitioners
apparently perceive that Western patients react faster and to less stimulation than Chinese
patients. Again there is disagreement as to whether deqi should be obtained if using
electroacupuncture, as the stimulation is provided by the response to the
electroacupuncture itself (see Chapter 12).
Essentially, as a practitioner, you are looking for deqi as feedback during the needling
process, and adjusting your needle technique as a result of this feedback to elicit deqi. It is
therefore important that the patient is aware of and understands deqi so as to guide and aid
the practitioner.
Deqi as experienced by the patient is variously described as dull, aching, heavy, numb,
radiating, spreading and tingling. The sensation of once having experienced deqi is
unmistakable and is an unusual experience. Experiencing deqi as the practitioner is
described as a fish biting a hook, needle grasp or a twitch response; these are generally
attributed to the mechanical behaviour of the soft tissues surrounding/contracting around
the needle. There may well be visible signs of deqi, including the twitch response, muscle
tension, trembling, twitching, spasm and fasciculation. There may be redness around the
needle insertion site indicating release of neuropeptides. Incorrect needling or missing the
point has been described in classical texts as needling into a void, presumably describing
the lack of feedback via the soft tissues and needle grasp.
Deqi is a complex phenomenon and may be influenced by a variety of factors. Patients
may be inaccurate in reporting needle sensations as they wish to avoid further needling.
They may not communicate accurately (or have the vocabulary for) what they are
experiencing. Deqi is a subjective experience and is influenced by many factors, such as
the constitution of a patient, severity of the illness, location of the acupuncture points and
the needling techniques (Lundeberg 2013). Patients vary enormously in their response to
acupuncture treatment: some will be extremely strong reactors, making their response
greater to fewer needles, and so will need less treatment; whereas some patients will feel
very little with lots of needles and lots of needle manipulation. In addition, each
acupuncture treatment will include different points which will be needled at different
depths with or without manipulation to produce differing results. The patient will also
have a limit to the sensations that they can identify, especially when considering the
possible number of acupuncture points used in a treatment.
Some practical suggestions
The practice of acupuncture is a diverse one, and when it comes to acupuncture needling
there is no wrong or right way of doing it (as long as it is safe), as it is an individualized
practice. The following are some suggestions based on observations and experiences that
you may find helpful in your acupuncture practice.
Prior to commencing acupuncture, a description of the possible sensations produced
by needling (deqi) must be accurately described to the patient. In patients with myofascial
pain, the strong possibility of reproducing their symptoms must be described. Ideally,
patients must be able to distinguish between deqi and pain. Communicate with the patient
during needling and ask for clarification on the sensations felt by the patient. Some
patients will struggle to communicate effectively, and in these cases it is best to ask
simple, well-defined questions such as Is it reproducing your pain? or Does it feel dull
and achy? to aid feedback as to whether or not deqi has been obtained.
Thicker needles are generally thought to produce deqi more easily, whereas needle
grasp is less likely to happen when using smaller gauge needles that are highly polished,
such as Japanese needles. However, with time and practice the same results can be
generated with minimal discomfort to the patient (White, Cummings and Filshie 2008).
During needling it is extremely important that the practitioner focuses all of their
attention on the needle, as needle grasp will be felt via the needle, which is essentially a
very fine piece of metal. Again, when using very fine well-polished needles, this can be
extremely subtle, but with time and practice it will become second nature and more
intuitive.
Although it would be quite unacceptable to attempt most forms of treatment without
defining the dose, acupuncture has so far remained without any means of quantification
(Marcus 1994). For this reason, for the first few treatments it would be advisable to needle
a few points and monitor the patients reaction. This approach also has the benefit that
future acupuncture treatments can be repeated using the same points or modified
accordingly depending on the response. It is far better to needle a few points with
precision and purpose and proceed with some caution, as opposed to blanket-bombing the
patient with multiple needles.
Deqi may occur at any depth when needling. This may vary from shallow to deep, and
sometimes a variety of needle depths are used during treatment to produce a variety of
deqi responses (Nugent-Head 2013). If no deqi has occurred, needle manipulation may be
used, including rotation, lift and thrust, flicking and twirling, to stimulate it. Again, the
intensity of deqi is variable: it may last for a few seconds, it may slowly occur, it may
suddenly occur or it may last for one minute or 20 minutes. Before any needle
manipulation, it is worth trying some very fine adjustments, as these can suddenly produce
dramatic deqi in patients. If sharp, shooting sensations are felt by a patient, then the
possibility that the needle has been inserted directly into a nerve must be considered and
withdrawal of the needle must be done immediately.
When needling, look for visible signs of deqi as described, but also monitor other
visible clues to the patients response such as rate of breathing, clenched fists, curled toes
and sweating.
Mechanisms of action
It is widely thought that the mechanical deformation of sensory nerves (both myelinated
and unmyelinated) in skin and muscle is responsible for the deqi sensation. Deqi can be a
rich sensory experience and one that is stimulated by multiple nerve fibres (Wang et al.
1985). The main sensory nerves and possible relationship to acupuncture sensations are:
Type II: numbness
Type III: heaviness, distension, aching
Type IV: soreness.
Some Western medical practitioners have proposed that deqi is simply an indication that
the correct nerves have been stimulated (White et al. 2008). However, this does not
explain the more subtle needling in some styles of Japanese acupuncture.
Langevin et al. (2001) argue that needle grasp is not due to muscle contraction but
involves connective tissue. The authors demonstrated that needle rotation strengthens the
mechanical bond between needle and connective tissue, which deforms the connective
tissue surrounding the needle, delivering a mechanical signal into the tissue (possibly by
deforming the sensory nerves). Increasing mechanical stresses by needle rotation
surrounding connective tissue activates sensory receptors away from the site of needle
insertion, possibly explaining sensations away from the needle site.
Interestingly, Langevin et al. (2001) demonstrated that lift and thrust techniques,
which are commonly used in practice, result in a gradual build-up of torque at the needle
tissue interface. This perhaps explains why this technique is more tolerable for patients.
Langevin et al. also proposed that acupuncture points may serve as a guide to where
manipulation of the needle can result in a greater mechanical stimulus.
Langevin et al. (2001) further hypothesized that deqi causes acupuncture-induced actin
polymerization in connective tissue fibroblasts, which may cause these fibroblasts to
contract, causing further pulling of collagen fibres and a wave of contraction and cell
activation through connective tissue.
Sandberg et al. (2003) showed that deep needling with deqi (at GB-21, Upper
Trapezius) in healthy subjects produced the most amount of blood flow. The same study
suggested that the intensity of stimulation should be taken into consideration when
treating chronic pain conditions, as the data suggested that there was no significant
increase in blood flow with deqi when needling the patients with fibromyalgia.
The evidence so far
Bovey (2006, p.27) states: There is no evidence as yet that any given type of acupuncture
is better or worse than any other. Indeed, there are virtually no data at all comparing the
clinical effects of different approaches. At present we know that acupuncture works
through a variety of different mechanisms, but different styles of acupuncture have yet to
be clinically evaluated. As manual therapists we would never treat two patients the same;
perhaps we would use the same techniques, but would adapt them accordingly to each
patient. The same is true of acupuncture. With experience and intuition, greater clarity will
emerge as to the appropriate dosage when needling different patients. For the practitioner,
awareness of the different possibilities and variables when needling patients is important
so as not to be alarmed when encountering differing responses.
References
Bovey, M. (2006) Deqi. Journal of Chinese Medicine 81, 1829.
Langevin, H.M., Churchill, D.L., and Cipolla, M.J. (2001) Mechanical signalling through connective tissue: a
mechanism for the therapeutic effect of acupuncture. FASEB J. 15, 22752282.
Lundeberg, T. (2013) To be or not to be: the needling sensation (de qi) in acupuncture. Acupunct. Med. 31, 129131.
MacPherson, H., Thomas, K., Walters, S., and Fitter, M. (2001) A prospective survey of adverse events and treatment
reactions following 34,000 consultations with professional acupuncturists. Acupunct. Med. 19, 2, 93102.
Mao, J.J., Farrar, J.T., Armstrong, K., Donahue, A., Ngo, J., and Bowman, M.A. (2007) De qi: Chinese acupuncture
patients experiences and beliefs regarding acupuncture needling sensation an exploratory survey. Acupunct. Med.
25, 4, 158165.
Marcus, P. (1994) Towards a dose of acupuncture. Acupunct. Med. 12, 7882.
Nugent-Head, A. (2013) Ashi points in clinical practice. Journal of Chinese Medicine 101, 512.
Sandberg, M., Lundeberg, T., Lindberg, L.G., and Gerdle, B. (2003) Effects of acupuncture on skin and muscle blood
flow in healthy subjects. Eur. J. Appl. Physiol. 90, 12, 114119.
Wang, K.M., Yao, S.M., Xian, Y.L., and Hou, Z.L. (1985) A study on the receptive field of acupoints and the
relationship between characteristics of needling sensation and groups of afferent fibres. Evid. Based Complement.
Alternat. Med. 2013, 483105. Online. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3766991, accessed on
23 July 2015.
White, A., Cummings, M., and Filshie, J. (2008) An Introduction to Western Medical Acupuncture. Edinburgh: Churchill
Livingstone.
Chapter 10
Planning Treatment
Treatment strength and the patients sensitivity
There is no golden rule for using or incorporating dry needling/medical acupuncture into
your treatment protocol, and patients new to acupuncture techniques will respond very
differently. As such, each patient and treatment is to be taken on its own merit and
adjusted accordingly.
It is advised that less is more with new patients, and therapists should avoid over-
stimulating in the first few sessions, by which we would advise that new patients are
treated with fewer needles, and those needles are not overly stimulated until the patients
tolerance and how the patient reacts to treatment has been established.
Not everyone will respond to the use of dry needling, and with patients that show no
response to treatment after several sessions, then the use of electroacupuncture would be
appropriate as a way of increasing the strength and effectiveness of the technique.
Treatment duration
In terms of needle duration, it has been seen that acute conditions respond to short
needling times, whereas chronic conditions respond to longer duration. That being said,
treatment can last anywhere from inserting and immediately removing the needles, to
leaving the needles in for up to 30 minutes. Patients should not be left alone during the
treatment, and tolerance and sensitivity should be verbally monitored to ensure patient
comfort.
Acupuncture before, during or after manual therapy?
This will be down to the judgement of the therapist. There is no strict rule that
acupuncture must only be used before soft tissue work or manipulation, for example it
simply doesnt work like that. Treatment needs to be individualized to the specific patient,
and the therapist may wish to use acupuncture techniques before, during or after other
therapeutic modalities. The only considerations are to ensure that the skin is clean and
clear of lotions or oils, all the needles have been fully removed before other therapeutic
modalities are employed, the patient is not bleeding and you have followed the safety
guidelines already stipulated.
Step-by-step guide
Before starting treatment, ensure that:
you have all your equipment ready and to hand
the patient is in a comfortable position
the skin is clean and clear of oils or lotions
a case history has been fully completed and the patients previous sensitivities and
treatment reactions have been noted
new patients have been informed of possible treatment reactions, and have a clear
understanding that they can stop the treatment at any point if it becomes
uncomfortable
the area being worked on is clear and free of clothing.
The following is relevant during the treatment:
Locate and palpate the point of pain within the muscle, identify any risk factors or
neurovascular structures to be aware of before needling, and ensure that you use
the correct grip of the target muscle.
Choose the correct needle insertion technique for the muscle: perpendicular,
oblique or inferior techniques depending on anatomical structures around the site.
Choose your style of handling the needle and insert it into the target muscle.
Check patient comfort, and then stimulate the needle to elicit a twitch response.
Ensure you are aware of the treatment time for needle retention depending on
whether the condition is chronic or acute.
Once the treatment has finished, remove all the needles and place them into a
sharps bin, and inform the patient that all the needles have been removed.
Check for any bleeding, and give appropriate aftercare advice.
Note down any immediate treatment reactions, whether good or bad.
Part IV
NEEDLING TECHNIQUES
Chapter 11
Muscles
Techniques and Clinical Implications
Supraspinatus
Palpation: Sitting within the supraspinatus fossa, the supraspinatus runs along and
underneath the acromion, attaching onto the greater tubercle of the humerus. Palpate the
spine of the scapula as your landmark and move upwards into the fossa; the fibres of the
supraspinatus run parallel to the spine.
Pain referral pattern: The supraspinatus will primarily refer pain to the anterior portion
of the shoulder and to the lateral epicondyle region; there are secondary referral sites in
the posterior shoulder and upper arm.
Needling technique: With the patient prone, palpate for areas of pain. The needle should
be inserted near the supraspinatus fossa towards the bulk of the muscle with the direction
in a longitudinal plane, aiming towards the greater tubercle of the humerus.
Adaptations: The patient should ideally be prone or side lying. Needle length between 1
inch and 1.5 inches.
Clinical implications: This technique, whether used with the patient prone or side lying,
will take the needle towards the front of the scapula, and expose the risk of passing into
the intercostal space and towards the pleural cavity.
The lung in a thin person lies 0.51 inch under the skin and there is the danger of
pneumothorax if the needle is inserted too deeply. It is advised to use perpendicular
needling techniques for areas close to the lungs, and in some cases it is also advised to
grasp the muscle and pick it up to reduce the risks further.
Figure 11.1 Supraspinatus trigger points
Infraspinatus
Palpation: The infraspinatus sits within the infraspinatus fossa, with the bulk of the
muscle being superficial to palpate; its insertion is on the greater tubercle of the humerus.
Palpate the spine of the scapula as your landmark and move downwards into the
infraspinatus fossa; the fibres run laterally towards the greater tubercle of the humerus and
sit underneath the bulk of the deltoid.
Pain referral pattern: The infraspinatus will primarily refer pain to the anterior portion
of the shoulder and to the area of the mid-thoracic, the medial border of the scapula. There
are secondary points in the cervical spine and, more often, in the anterior portion of the
arm, forearm and into the thumb.
Needling technique: Palpate the infraspinatus and highlight any areas of pain. The needle
will be placed directly into that point within the muscle belly in a perpendicular direction
towards the scapula.
Adaptations: The patient should ideally be prone or side lying. Needle length between 1
inch and 1.5 inches.
Clinical implications: Due to its location sitting above the bulk of the scapula, as long as
there is no compromise within the scapula allowing the needle to penetrate through, there
are no clinical implications.
Figure 11.2 Infraspinatus trigger points
Deltoid
Palpation: The deltoid sits in a triangle shape at the top of the shoulder, split into three
sections: the anterior, medial and posterior fibres of the muscle. The three heads of the
deltoid all originate from the lateral one third of the clavicle, acromion and spine of
scapula. Insert into the deltoid tuberosity, which is also the same insertion point for the
trapezius.
Pain referral pattern: The deltoid will primarily refer pain very locally, to the anterior
and posterior shoulder girdle. There are secondary sites in the anterior and posterior
forearm.
Needling technique: Ideally sit the patient upright; then you can needle all the sections of
the muscle from the anterior, medial and posterior. If this is not possible, then you will
need to move the patient from supine to needle the anterior and medial, and to prone to
affect the posterior muscle. Due to the location and muscle bulk, you can needle directly
into any areas of pain that are highlighted.
Adaptations: You may need to use needles from 1 inch to 2 inches depending on the
musculature of the patient.
Clinical implications: None.
Figure 11.3 Deltoid trigger points
Subscapularis
Palpation: The subscapularis sits within the subscapular fossa and inserts into the lesser
tubercle of the humerus and the front of the capsule of the shoulder joint.
Pain referral pattern: The subscapularis will refer pain very locally around the location
of the muscle. It has also been shown to primarily refer pain into the carpal tunnel area of
the forearm.
Needling technique: To gain access to the bulk of the muscle, have the patient supine,
place the arm above the patients head to expose the muscle bulk and use a perpendicular
needling technique.
Adaptations: Patient should ideally be prone or supine. Needle length between 2 inches
and 3 inches.
Clinical implications: This technique, whether used with the patient prone or supine, will
take the needle behind the scapula, and expose the risk of passing into the intercostal
space and towards the pleural cavity.
The lung in a thin person lies 0.51 inch under the skin and there is the danger of
pneumothorax if the needle is inserted too deeply. It is advised to use shallow needling
techniques for areas close to the lungs, and in some cases it is also advised to grasp the
muscle and pick it up to reduce the risks further.
Figure 11.4 Subscapularis trigger points
Teres minor
Palpation: The teres is a small muscle situated between the lateral border of the scapula,
inserting into the greater tubercle of the humerus. It sits between teres major and the
infraspinatus. The muscle is small and can be quite difficult to grasp.
Pain referral pattern: Localized pain referral into the upper back, shoulder and arm.
Needling technique: With the patient prone, drop the arm off the couch and work from
the border of the scapula as your landmark. Move laterally off the lateral border and you
will slide onto the teres minor. To confirm your location, ask the patient to laterally rotate
the shoulder and the teres minor will contract. Grasp the muscle with your thumb and
forefinger, bring the muscle slightly away from the rib cage, and the needling insertion
will be lateral and towards the abdomen.
Adaptations: The patient should ideally be prone or side lying. Needle length between 1
inch and 1.5 inches.
Clinical implications: By grasping the muscle and bringing it away from the rib cage,
you reduce the risk of compromising that area. The needle direction is always away from
the rib cage. There are no clinical implications.
Rectus femoris
Palpation: The rectus femoris is one of four parts of the quadriceps femoris group of
muscles that extend the leg at the knee joint, and is located between the tensor fasciae
latae and sartorius. The rectus femoris helps to flex the thigh and also anteriorly tilts the
pelvis, at the hip joint. With the patient in supine position, with thighs on the table and
legs hanging off, stand to the side and palpate on the anterior surface, close to the hip.
Externally rotate the hip and resist flexion. Support with a hand on the distal leg, close to
the ankle joint, to provide resistance. Locate the rectus femoris via the proximal tendon of
the tensor fasciae latae or sartorius. Extend the leg and feel for the contraction of the
muscle and continue palpating distally.
Pain referral pattern: Pain is referred to the front and centre of the knee and can cause
problems fully flexing the knee and/or extending the hip.
Needling technique: With the patient in a supine position, use a perpendicular angle into
the bulk of the muscle, or into specific spots of pain within the muscle itself.
Clinical implications: There are no clinical implications within the rectus femoris. The
femoral artery lies very deep underneath the muscle, so if using much longer needles such
as 2 or 3 inches then caution should be applied.
Vastus medialis, vastus intermedius and vastus lateralis
Palpation: The vastus medialis, vastus intermedius and vastus lateralis make up three of
the four subcomponents of the quadriceps femoris. The three muscles contribute to the
extension of the knee. The quadriceps forms a trilaminar tendon insertion at the patella,
and the vastus medialis and vastus lateralis form an intermediate layer. The vastus
intermedius makes up the deep layer. Palpate whilst seated, with flexed knee and thigh
maintained in horizontal position. Stabilize and palpate the vastus medialis of the distal
medial thigh. Due to the depth of the muscle, to access the vastus intermedius lift the
rectus and palpate from the medial or lateral side.
Pain referral pattern: The quadriceps femoris muscle group, which includes the vastus
medialis, vastus intermedius and vastus lateralis, is responsible for the referred pain to the
front and inner side of the knee and to the mid-thigh area. Vastus medialis can also refer
deep pain to the knee joint.
Needling technique: This group of muscles is needled in the same technique. With the
patient supine, identify the target muscle and needle perpendicularly into the muscle or
directly into any painful spots within the muscle itself.
Clinical implications: None.
Figure 11.8 Quadriceps muscle trigger points
Pectoralis minor
Palpation: Situated next to the rib cage and running perpendicular, the pectoralis minor
has its origins on the third, fourth and fifth ribs. Insert onto the coracoid process of the
scapula. Due to its location, several major structures run underneath the pectoralis minor:
the brachial plexus, axillary artery and vein.
Pain referral pattern: The pectoralis minor will refer pain locally and into the anterior
portion of the chest and shoulder.
Needling technique: With the patient supine, and with the arm slightly abducted, palpate
the lateral edge of the pectoralis major, and as you slide underneath this muscle you are
able to access the pectoralis minor. The needle should be inserted in an inferior/shallow
depth above the rib cage, and the needle should be pulsed laterally towards the coracoid
process. As with the latissimus dorsi, an alternative method is to pinch the muscle and
raise it up from the rib cage.
Adaptations: Patient should ideally be prone or side lying. Needle length between 1 inch
and 1.5 inches.
Clinical implications: When needling the pectoralis minor, care should be taken not to
needle into the intercostal space or penetrate the rib cage an inferior needling technique
is recommended for this area. Avoid deep needling, being aware of the structures which
are situated below the muscle and the potential for neurovascular compression by this
muscle.
Figure 11.9 Pectoralis major trigger points
Figure 11.10 Pectoralis minor trigger points
Coracobrachialis
Palpation: This small yet important muscle is situated deep in the arm. Its origins are at
the coracoid process of the scapula and it inserts into the mid-shaft of the humerus. To
palpate the coracobrachialis, get the patient to lay supine, and abduct and laterally rotate
the shoulder. As you palpate the medial side of the arm towards the armpit, get the patient
to gently adduct the arm horizontally and the coracobrachialis will contract.
Pain referral pattern: The coracobrachialis will refer pain locally and into the anterior
portion of the shoulder and posterior aspect of the arm.
Needling technique: The patient should be lying in a supine position, with the medial
portion of the upper arm exposed by abducting and laterally rotating the shoulder. The
needle is inserted directly into the muscle belly near to the coracoid process.
Clinical implications: This area may be sensitive to bruising, and its close proximity to
the neurovascular bundle of the upper arm should be considered when needling. Avoid the
brachial artery.
Figure 11.11 Coracobrachialis trigger points
Biceps brachii
Palpation: The biceps brachii is located on the anterior border of the humerus. This thick
muscle belly has two origins: the short head of the bicep originates in the coracoid
process, and the long head is situated close by in the supraglenoid tubercle. As these two
heads merge, insert into the tuberosity of the radius and the aponeurosis of the biceps
brachii.
Pain referral pattern: The biceps brachii will refer pain locally and into the anterior
portion of the shoulder and arm.
Needling technique: With the patient supine, grip the bicep and pick up the muscle
slightly, allowing you to accurately palpate any areas of pain. The needle should be
inserted laterally; this avoids the neurovascular bundle on the medial/inner arm.
Adaptations: The patient should ideally be supine or side lying. Needle length between 1
inch and 1.5 inches.
Clinical implications: Limited. If the application of the needle is from the lateral aspect,
avoiding the medial part of the muscle, you reduce any risk of compromising the radial
nerve or affecting the neurovascular bundle. Avoid the brachial artery.
Figure 11.12 Biceps brachii trigger points
Triceps
Palpation: Made up of three heads, this muscle is the only one situated on the posterior
arm. It is superficial and easy to palpate and needle. The origins of the long head are at the
inferior tubercle of the scapula, the lateral head is on the proximal half of the humerus,
and the medial head is on the posterior surface of the distal half of the humerus. These
three heads insert into the olecranon process.
Pain referral pattern: The triceps can refer primarily locally and to the front of the arm.
Also, it has a secondary referral to the medial and lateral epicondyle and olecranon.
Needling technique: With the patient prone, palpate the muscle for any areas of pain, and
the needle insertion will be directly into any highlighted trigger points.
Adaptations: The patient should ideally be prone or side lying. Needle length between 1
inch and 1.5 inches.
Clinical implications: None.
Masseter
Palpation: Situated between the zygomatic arch and the angle and ramus of the mandible,
the masseter is a thick, powerful band of muscle that is easily palpated between these two
points. To confirm, ask the patient to gently bite down, tensing the jaw muscles and
allowing the masseter to rise up.
Pain referral pattern: The masseter will refer to the cheek and jaw on the affected side
and into the temporomandibular joint, causing pain.
Needling technique: With the patient either supine or side lying, locate the masseter
muscle, ensure the patient is relaxed and insert the needle directly into the muscle at a
perpendicular angle.
Clinical implications: The therapist should be aware of needle length and needle depth
when needling this muscle group. Avoid needling too deeply in case the needle punctures
the inside of the mouth.
Figure 11.14 Masseter trigger points
Temporalis
Palpation: Located roughly an inch superiorly above the zygomatic arch and stretching
out to the temporal fossa and fascia, the temporalis muscle spans a thick muscular band.
Reconfirm the location by asking the patient to gently bite down and the muscle will
contract.
Pain referral pattern: The temporalis can refer pain into the eyebrow and temple area on
the affected side, and into the temporomandibular joint.
Needling technique: The muscle can be needled in two different ways. Ensure the patient
is either supine or side lying, and either use an inferior needle technique to thread the
needle towards the temporal fossa, or perpendicularly into the bulk of the muscle.
Clinical implications: Locate the superficial temporal artery first, and avoid needling
directly into that, as any bleeding can cause large bruising around that area.
Figure 11.15 Temporalis trigger points
Upper trapezius
Palpation: This is one of the most commonly treated muscle groups within manual
therapy and an area where most people can feel pain and discomfort. It stretches from as
far up as the occipital protuberance across to the clavicle and acromion process and down
to the level of T12. The trapezium is easily located as the fibres form the bulk of muscle
sitting across the top of the shoulders bilaterally. Grasp the trapezius muscles and bring
them slightly superiorly away from the bony structures.
Pain referral pattern: This large muscle can refer to a number of places, primarily into
the posterior head and neck, temporomandibular joint and into the mid-thoracic spine, but
also into the posterior aspect of the shoulder.
Needling technique: Perpendicular needling into the bulk of the muscle is the safest
technique for this area. However, be aware of the apex of the lung. When using longer
needles, do not use an inferior needling technique. The handle of the needle should never
point towards the pelvis.
Adaptations: Depending on the size of the patient, use a 11.5 inch needle into this area.
The patient should be aware that the trapezium muscles can respond strongly to
acupuncture in this area and a strong local twitch response can be felt.
Clinical implications: This technique, whether used with the patient prone or side lying,
will take the needle towards the front of the scapula, and expose the risk of passing into
the intercostal space and towards the pleural cavity.
The lung in a thin person lies 0.51 inch under the skin and there is the danger of
pneumothorax if the needle is inserted too deeply. It is advised to use shallow needling
techniques for areas close to the lungs, and in some cases it is also advised to grasp the
muscle and pick it up to reduce the risks further.
Figure 11.16 Upper trapezius trigger points
Levator scapula
Palpation: Work through the upper fibres of the trapezius in order to palpate the levator
scapula muscle. The levator scapula spans from the medial border of the scapula to the
transverse processes of the upper cervical spine (C1C4). To accurately locate the muscle,
locate the superior medial border of the scapula and drop off that superior angle. Palpate
the levator muscle fibres as they angle laterally towards the cervical spine.
Pain referral pattern: The levator scapula will refer pain locally over the bulk of the
muscle, from the medial border of the scapula and mid-thoracic spine, and it will refer
superiorly into the cervical spine.
Needling technique: With the patient either prone or side lying, locate the levator scapula
and use a perpendicular angle of needle insertion into the muscle belly.
Clinical implications: As with muscle groups in the vicinity of the rib cage, it is crucial to
avoid directing the needle towards the pleura of the lung. Use a perpendicular angle into
the muscle bulk, and never angle the needle inferiorly towards the rib cage or pelvis in
order to make sure the lung is avoided at all times.
Figure 11.17 Levator scapula trigger points
Suboccipitals
Palpation: There are eight muscles that make up the suboccipitals and they are some of
the deepest muscles in the superior cervical spine. They can be a contributing factor in
chronic neck and head pain, and patients suffering with headaches. With the patient prone,
locate the first palpable spinous process of C2, and the transverse process of C1, as the
start point of the suboccipital muscle group. Trace out to the superior nuchal lines the
outer portion of the suboccipitals.
Pain referral pattern: The referral pattern for the suboccipital muscles refers into the
high cervical spine, and laterally around to the temple and eye brow.
Needling technique: The needle is inserted perpendicularly into the bulk of the muscle;
the therapist should then angle the needle slightly and advance it in the direction of the
patients nose, in order to access the bulk of the muscles. Use four needles into this group
and this will resemble a TCM technique called a peacocks tail: two needles bilaterally
will be inserted laterally and inferiorly to the external occipital protuberance; the second
two needles will then be inserted between those needles and the mastoid process.
Adaptations: 1 inch needles are advised to be used in this area.
Clinical implications: Although extremely uncommon and difficult to do with the length
of the needles, you should be aware of the location of the vertebral artery and foramen
magnum, and these structures are to be avoided.
Sternocleidomastoid
Palpation: This thick portion of muscle can be found on the lateral portion of the neck,
very superficially forming a large V from the manubrium sterni and medial section of the
clavicle and stretching up to the mastoid process of the temporal bone, at the superior
nuchal line. It is a strong neck stabilizer and can be greatly affected in cases of whiplash.
Pain referral pattern: Pain can be felt locally, into the head and neck, and into the cheek
and jaw.
Needling technique: The patient may be supine or side lying. Gently move the
sternocleidomastoid away from the midline of the throat using a pincer grip with your
non-needling hand. The angle of needle insertion is perpendicular to the table while
supine, or perpendicular to you if the patient is side lying. You are able to needle the
sternocleidomastoid mid-belly, at the sternal and clavicular attachment sites.
Clinical implications: The carotid artery is the main concern with this technique. The aim
of lifting the sternocleidomastoid away from the midline of the throat is to move the
sternocleidomastoid away from the carotid arteries and thus minimizing the risk of
needling the carotid artery.
Figure 11.20 Sternocleidomastoid trigger points
Quadratus lumborum
Palpation: With deep and some superficial layers, the quadratus lumborum sits under the
layers of the lumbar erector spinae muscles. This structure is a common contributor to
lower back pain due to its connection to the spine and pelvis.
The muscle starts at the iliac crest and iliolumbar ligament, fanning up to the 12th rib
and the transverse processes of the lumbar spine. As it is deep, it can be difficult to locate
and palpate for acupuncture. With the patient prone, locate the spinous process of the
lumbar spine and move laterally. Then move your fingers across the erector spinae
muscles. The muscle will drop, allowing palpation towards the belly button at a 45-degree
angle towards the quadratus lumborum.
Pain referral pattern: Lower back, iliosacral and gluteal pain.
Needling technique: The quadratus lumborum muscle can be needled in the prone or
side-lying position. The needles will be placed between the iliac crest and the 12th rib. At
the level of L4 (approximately) is the main window of opportunity to access the quadratus
lumborum. The needle angle should aim towards the transverse process to achieve the
correct depth and be angled towards the midline of the body or the umbilicus.
Clinical implications: The upper needle is angled towards the patients contralateral
posterior superior iliac spine and not inserted above the 12th rib. This is to avoid any risk
of penetration of the kidney.
Cervical multifidus
Palpation: The cervical multifidus muscles insert onto the lower cervical facet capsular
ligaments and the cervical facet joints. They are small, strong muscles that can be a direct
source of pain in traumatic injuries such as whiplash where the head is thrown forwards
and backwards at speed.
Pain referral pattern: Pain can be felt locally, into the head and neck, and into the cheek
and jaw.
Needling technique: With the patient either prone or supine, insert the needle in a
perpendicular direction to the skin, aiming between the articular processes between C4
and C7.
Precautions: When using this technique, it is advised that you avoid direct needling
towards the spinous processes to avoid infiltration of the spinal canal.
Scalenes
Palpation: The scalenes are made up of three lateral vertebral muscles the scalenus
anterior muscle, scalenus medius and scalenus posterior and pass up from the ribs into
the sides of the neck. The muscles elevate the first rib to allow breathing and facilitate
movement and rotation of the neck. The scalene muscles elevate the first two ribs when
the muscles are fixed from above, and bend and flex the spinal column when working
from below. The scalenes can be easily palpated seated or supine. Rotate the head and
neck to the opposite side, at the spinal joints. Laterally flex the head and neck to the same
side. Resist lateral flexion.
Pain referral pattern: Pain in the scalenes is variable and complex and is usually referred
to other areas of the body. Pain spreads from the neck into the chest and upper back and
through the arm to the hand, and can also trigger symptoms associated with sinuses,
swallowing and hearing.
Needling technique: While the patient is supine, ask them to take a sharp intake of breath
while palpating the area. This will enable you to locate the scalenes.
To access the anterior portion, you must locate the anterior triangle formed by the
clavicular attachment of the sternocleidomastoid, the base of the clavicle and the jugular
vein.
The direction of needling for the anterior scalene is perpendicular to the skin and
approximately 11.5 inches above the clavicle. You must direct the needle towards the
transverse process.
The middle scalene muscles are accessed through the triangle of the base of the
clavicle, posterior scalene muscle and the brachial plexus. The direction of needling for
the middle scalene is towards the posterior tubercle and transverse processes of the
cervical spine.
Clinical implications: You must needle the scalenes 11.5 inches above the clavicle to
minimize the risk of infiltrating the pleural space and impacting the apex of the lung.
Supinator
Palpation: The supinator is located in the upper forearm and is deeply concealed by
superficial muscles. It originates from the inferior aspect of the lateral epicondyle of the
humerus and the crest of the ulna. The flat supinator laterally wraps around the upper third
of the radius and inserts into the posterior, anterior and lateral aspects. The muscle is
responsible for the ordinary supinatory movements of the forearm. Fully flex the elbow to
midpronate the forearm. The muscle can be palpated once the arm is supinated against
resistance.
Pain referral pattern: Pain is referred locally and also into the wrist and the base of the
thumb. The backside web between the thumb and index finger can also be affected. The
supinator is primarily responsible for causing tennis elbow and movement-and-rest pain
in the outer elbow.
Needling technique: The supinator muscle can be needled with the patient supine or side
lying. The non-needling hand uses a pincer grip to lift the extensors away from the radius.
This allows access to the supinator muscle. Needling should be via the palmar side of the
extensors.
Clinical implications: There is a small risk that you may irritate a superficial branch of
the radial nerve. This may cause the patient moderate discomfort with some pins and
needles but will not have a lasting effect.
Figure 11.34 Supinator trigger point
Pronator teres
Palpation: The pronator teres is located between the inner elbow and the centre of the
radius bone in the forearm and is the most lateral of the superficial flexor compartment
muscles. The pronator teres passes laterally downwards and attaches via a flattened
tendon. The muscle pronates the forearm and helps to flex the elbow. The pronator can be
easily seen and palpated when the forearm is resisting pronation. The pronator quadratus
initiates pronation of the forearm and lies within the flexor compartment. The
inaccessible, fleshy, quadrangular-shaped muscle traverses the lower quarter of the
anterior surface of the ulna to the anterior radius surface. Isolate the radial artery pulse and
locate the anterior surface of the radius. Flex and pronate the wrist and use your thumbs to
explore the tissue and small contractions.
Pain referral pattern: Pronator pain is referred locally, predominantly towards the base
of the thumb.
Needling technique: The optimal position for this technique is the patient lying supine
with the forearm in the supinated position. Needling of this muscle is to the proximal,
medial portion, which is located slightly below the medial epicondyle.
Clinical implications: Needling should remain 0.51 inch below the medial epicondyle to
avoid the median and ulnar nerves.
Figure 11.35 Pronator teres trigger points
Serratus anterior
Palpation: The serratus anterior is a large muscle that is located between the scapula and
thorax, with origins to the lateral ribs. The serratus anterior lies alongside the underside of
the subscapularis and inserts on the undersurface of the scapulas medial border. From
behind, locate the lateral border of the scapula. From the lateral edge palpate inferiorly
using four fingers and work towards the ribs. Follow the section of the serratus to the
origin. Flex the shoulder and elbow. Resist protraction of the scapula to ensure the correct
location. The serratus posterior runs under the shoulder blade to the ribs. Palpating this
muscle requires moving the shoulder blade out of the way by reaching the arm across the
chest.
Pain referral pattern: Serratus anterior pain is typically referred to the side and lower
part of the shoulder blade. Serratus posterior pain is primarily referred locally and can
cause a deep pain under the shoulder blade. Pain can also be felt in the back of the
shoulder, elbow, back of the upper arm and forearm and the little finger.
Needling technique: Locate the muscle and, using a pinching technique, grip the muscle
and pull it slightly away from the intercostal space. Using an inferior needling technique,
insert the needle at a perpendicular angle. Avoid angling the needle towards the lungs.
Clinical implications: Due to its anatomical location near to the lung space, ensure that
you avoid needling towards the lungs at all times to ensure that the lung is not penetrated.
Gluteus maximus, gluteus medius and gluteus minimus
Palpation: Gluteus maximus, gluteus medius and gluteus minimus make up the gluteal
group of muscles and, as their names suggest, range in size. Gluteus maximus is the
largest and most posterior and originates at the posterior sacrum and ilium. The muscle
extends the femur, at the hip, and laterally rotates the hip.
Palpate by extending and laterally rotating the thigh, at the hip. As the muscle
contracts, palpate to discern the borders and tone.
Gluteus medius is partially superficial and located on the side of the hip. It originates
at the ilium crest and contracts and stabilizes the pelvis. Abduct the thigh at the hip and
feel for the contraction of muscle fibres. Use your thumbs to palpate the fleshy area.
Gluteus minimus is inaccessible and originates on the posterior ilium. This muscle works
with the gluteus medius during rotation and abduction of the femur at the hip.
Pain referral pattern: The glutes primarily refer pain to the lower back and locally to the
gluteal region. Gluteus minimus has a very large and complex distribution of referred pain
and can affect the tensor fascia latae, hamstrings, quadriceps, gastrocnemius and peroneal
muscle groups. The most common referred pain pattern is known as side sciatica.
Needling technique: The patient may be prone or side lying. The depth of the needle will
be dependent on the anatomy and the amount of adipose tissue. As the gluteus maximus is
the most superficial gluteal muscle, then the depth of needle may not need to be
substantial.
Clinical implications: If you irritate the sciatic or superior gluteal nerves and the patients
response does not ease, then remove the needle and possibly insert a new needle in a
slightly different location.
Obturator
Palpation: The obturator internus and obturator extermus form part of the six muscles that
make up the deep lateral rotator group, located in the pelvis. The muscles work together to
rotate the thigh at the hip and to contralaterally rotate the pelvis. The obturator extermus is
covered by the large quadratus femoris and is therefore not visible. To palpate, start from
the prone position, with the leg flexed at the knee joint. Place your fingers halfway
between the posterior superior iliac spine and sacrum apex. Rotate the thigh at the hip and
resist.
Pain referral pattern: Pain is localized and can be experienced as a full feeling in the
rectum. It is also possible that some pain may refer down the back of the ipsilateral thigh.
Needling technique: Ensure the patient is in a secure and comfortable position on the
couch, locate the muscle and insert the needle directly into the muscle belly or into a
specific point of pain.
Clinical implications: Avoid any deep neurovascular structures such as the sciatic nerve
when needling the obturator. If any neurological referral is felt, withdraw the needle and
reposition.
Tensor fasciae latae
Palpation: The tensor fasciae latae is a small muscle located on the lateral edge of the
anterior hip. The muscle helps to rotate the leg in opposite directions and works in
conjunction with the iliotibial band, which is a thick stabilizing tendon. Palpate by side
lying, with hip and knee flexed. Stand at the side and face the thigh. Using the palm of the
hand, locate the lateral femoral condyle and palpate the fibres along the thigh. Follow the
tendon to the belly of the tensor fasciae latae. Resist as the hip abducts.
Pain referral pattern: Pain is localized down the lateral front thigh, towards the knee. It
can also extend into the hip and down to the calf muscle.
Needling technique: This technique can be completed with the patient supine or side
lying. In either position it is best to support the patient in the normal areas such as the
knees. The direction of needling, whether supine or side lying, is to remain perpendicular
to the skin.
Clinical implications: None.
Figure 11.39 Tensor fasciae latae trigger points
Piriformis
Palpation: Piriformis is a small triangular muscle and one of six hip external rotators
located deep in the gluteus maximus and gluteus medius. These rotators help to coordinate
stabilization of the hip joint and also position the femoral head. As the most superior
external rotator, piriformis is also associated with the sciatic nerve. Palpate by side lying,
with hip and knee flexed. Stand at the side and face the thigh to locate the lateral edge of
the sacrum.
Following the oblique muscle fibres, slide the fingers towards the greater trochanter, to
avoid compressing the sciatic nerve. Palpate and follow the muscle fibres. Resist external
rotation of the hip.
Pain referral pattern: Pain is primarily referred to the sacroiliac region and can cause
nerve impingement symptoms that include numbness, muscle weakness, tightening and
tingling.
Needling technique: The patient may be prone or side lying. Locate the piriformis by
using the landmarks of the sacrum and the greater trochanter. Needle the piriformis
perpendicular to the table.
Clinical implications: If you irritate the sciatic nerve and the patients response does not
ease, then remove the needle.
Figure 11.40 Piriformis trigger points
Adductor
Palpation: The adductors are located in the inner hip musculature and originate from the
lower pelvic bone to the femur, towards the knee. The group of adductor muscles includes
the adductor magnus, which is one of the biggest muscles in the body, the adductor
longus, the adductor minimus, the adductor brevis, the gracilis and the pectineus. The
muscles work together to facilitate the adduction of the hip joint, and support outward and
inward rotation, extension and flexion. Palpate the adductor muscle bellies at the medial
side of the thigh. When the knee is extended, the muscles become more stretched and can
be palpated.
Pain referral pattern: Pain is localized in the hips and legs, with the adductor longus and
adductor brevis referring pain into the groin and down towards the knee and shin.
Needling technique: With the patient supine, position the affected leg in slight hip flexion
and external rotation. You may support the patients leg with yours or with pillows. Insert
the needle in an anteriorposterior (AP) direction into the adductor muscle required.
Clinical implications: Avoid needling through the femoral triangle, which is created by
the inguinal ligament, sartorius and adductor longus. Many neurovascular structures run
through this area and it must be avoided.
Gracilis
Palpation: The gracilis is a thin strap muscle that extends along the length of the leg, from
the point of origin on the pubis to the inside knee joint. Flat palpation, supporting the knee
with a pillow, relaxes the distal portion of the adductor longus so that the thin, ropelike
gracilis can be palpated from its insertion to the point where it becomes lost in the
adductor muscles. The relaxed position offers a moderate stretch.
Pain referral pattern: Pain in the gracilis causes a stinging superficial pain in the medial
thigh and down the inside of the leg. The pain can also be constant during rest.
Needling technique: It is best to keep the patient in a supine position to allow you to
externally rotate the hip to allow access to the gracilis muscle. Insert the needle
perpendicularly into any painful spots within the muscle.
Clinical implications: There are no neurovascular issues within this area, although
patients may be prone to bruising on sensitive areas of the body.
Sartorius
Palpation: The sartorius is a superficial muscle in the interior compartment of the thigh.
The longest strap muscle in the body has flattened tendons at the end and reaches down, in
a vertical line, from the upper attachment in the anterior superior iliac spine to the gracilis.
The muscle facilitates hip and knee flexion, lateral rotation and thigh abduction, which are
the movements required for cross-legged sitting. Palpate the sartorius muscle from the
origin to its pes anserine tendon insertion point. When lying supine with knee flexed, the
muscle can be easily palpated.
Pain referral pattern: The sartorius will primarily refer pain to the leg, ankle and foot.
Primary pain is focused in the anterior thigh, with numbness or tingling on the outer thigh.
Secondary symptoms include medial thigh pain and anteromedial knee pain.
Needling technique: As with the gracilis, keep the patient in a supine position and needle
into the sartorius in a perpendicular angle into the muscle belly.
Clinical implications: Consideration of the femoral nerve, artery and vein should be
taken into consideration when needling into this area.
Popliteus
Palpation: The popliteus muscle originates from three points the lateral femoral
condyle, fibula and posterior horn of the lateral meniscus. The muscle rises from the
proximal tibia and inserts into the posterior surface of the tibia, above the soleus. The thin
and flat triangular popliteus muscle wraps around the lower section of the femur and
provides flexion of the knee joint and lateral rotation of the femur. The muscle is most
accessible at the lower medial end and upper lateral end of the muscle belly. In prone
position, palpate directly between the semitendinosus tendon and medial head of the
gastrocnemius muscle. Flex the knee, and the foot at the ankle, to slacken the muscles.
The soleus muscle can be laterally displaced to partially uncover the popliteus.
Pain referral pattern: Popliteus primary pain referral is localized in the leg, ankle and
foot and refers to posterior knee pain.
Needling technique: With the patient either prone or side lying, locate the muscle behind
the posterior aspect of the knee. Use an inferior needling technique to needle the muscle
laterally, avoiding deep perpendicular needling of the posterior knee.
Clinical implications: Be aware of the neurovascular bundle which sits just behind the
popliteus muscle. Using an inferior technique to needle the muscle laterally will avoid
contacting this delicate structure. If the patient does feel a strong referral from the nerve,
then remove and replace the needle.
Plantaris
Palpation: The small plantaris muscle is located in the posterior aspect of the leg, and
forms part of the posterosuperficial compartment of the calf. Along with the
gastrocnemius and soleus, the thin muscle belly and long thin tendon make up the triceps
surae muscle.
The plantaris originates from the lateral supracondylar line of the femur and from the
oblique popliteal ligament located in the posterior aspect of the knee. Palpation of the
muscle is possible in the popliteal fossa and the medial aspect of the common tendon. In
prone position, flex the leg and cover the heel with the distal hand. Use the forearm to
create resistance for the foot and knee flexion. Palpate the muscle in the popliteal fossa
and Achilles tendon.
Pain referral pattern: The plantaris primarily refers pain in the posterior aspect and
plantar surface of the heel. This can include the distal end of the Achilles tendon and the
sacroiliac joints on the same side of the body. Pain is referred to the posterior of the knee
and into the calf region.
Needling technique: Locate the upper lateral head of the gastrocnemius muscle and
locate the plantaris muscle. Needle into the muscle in either a perpendicular or lateral
direction.
Clinical implications: Be cautious around the tibial and peroneal nerves. If the patient
feels a strong referral, then the needle should be removed and replaced nearby.
Figure 11.49 Plantaris trigger point
Peroneals
Palpation: The peroneal muscle group is made up of two muscles the peroneus longus
and peroneus brevis and is located within the peroneal compartment, in the lower leg
region. The muscles can be easily seen when the foot is lowered, as they form the surface
of the lateral lower leg. The muscle tendons run towards the foot behind the lateral
malleolus and ventrally along the edge of the foot. The peroneus longus and peroneus
brevis are responsible for moving the upper and lower ankle joints. Palpate the hollow
behind the malleolus and the tendons that pass under and over the peroneal tubercle. The
peroneals brevis can be palpated to its insertion.
Pain referral pattern: The primary peroneal pain refers over the lateral malleolus of the
ankle and over the lateral aspect of the foot and lateral heel region. The outside edge of the
shin is a secondary referral site.
Needling technique: Locate the muscle belly and angle the needle towards the fibula,
with the needle being inserted in a perpendicular angle towards the skin.
Clinical implications: A caution is the location of the common peroneal nerve which sits
underneath the muscle. The more superficial peroneus nerve also lies within the area.
Avoid direct contact of the nerve; and if the patient indicates a strong electrical referral,
then the needle should be removed and replaced nearby.
Figure 11.50 Peroneal muscle trigger points
Electroacupuncture
Introduction
The use of electrotherapy within medicine is not a new concept; indeed, it has a long
history of genuine medical application. The earliest reference of its application was found
in ancient Greece, where electric eels were used in clinical footbaths to relieve pain and
enhance blood circulation (Garrison 1921). Today, electrotherapy is applied with a
scientific basis and has a number of therapeutic uses, including wound healing, pain
control and fracture repair (Gildenberg 2006).
Electroacupuncture (EA) is a technique of acupuncture which utilizes the electrical
stimulation of needles. This chapter reviews the theoretical mechanisms of EA, the
scientific evidence behind its effectiveness, its clinical implications, safety guidelines and
some practical suggestions for use in clinic.
What is electroacupuncture?
EA is a modified form of traditional manual acupuncture in which an electrical current is
applied between pairs of acupuncture needles using a device which controls the frequency
and strength of the electrical current being delivered. During a standard EA session,
several needle pairs can be stimulated simultaneously, usually for 1020 minutes, but
rarely exceeding 30 minutes (Noordergraaf and Silage 1973).
The use of electrotherapy has a long history, but todays practice owes much to the
experimentation in China post-1950 (Dharmananda 2002). Professor Ji-Sheng Han from
Beijing Medical University conducted a series of experiments to produce analgesia. This
discovery led to EA devices being used on patients undergoing surgery, to the extent that
11 per cent of patients did not require any anaesthetic. This was widely misreported, with
news spreading that in China patients were undergoing surgery without anaesthesia. Often
EA was supplemented with opiates and anaesthetics, giving the impression that patients
were awake with no anaesthesia. It was these reports and the rise in acupuncture use in
general during the Cultural Revolution that renewed the interest in EA in the West.
Typically EA is no longer used as an analgesic substitute but is still used in the reduction
of pain pre- and post-surgery.
Today EA is mainly used as an effective alternative and complementary treatment to
treat acute and chronic pain. It is reported to produce analgesia in chronic pain conditions
where manual acupuncture (MA) has been shown to be ineffective. Lin and Chen (2008)
suggest that the electrical stimulation of acupuncture points provides the therapeutic
effects of MA and transcutaneous electric nerve stimulation (TENS) combined. In contrast
to classical acupuncture, EA is preferred by most studies, since it can be easily
standardized by characteristics such as frequency, waveform and voltage.
EA uses the same acupuncture points as MA to attain deqi, a sensation of heaviness,
soreness or numbness (Ahn et al. 2008); however, Dharmananda (2002) states that there
are some benefits of using EA over MA:
It substitutes the need for the prolonged manual manipulation of needles by
providing a continued stimulus.
It affords the exact amount of needle stimulation required to a patient.
It can generate a much stronger stimulation, if needed, without eliciting any tissue
damage which may be associated with the manual manoeuvring of needles.
It provides more flexibility in controlling the stimulus frequency and amount than
MA.
EA may have greater effects than MA in many situations, including increased and
sustained pain reduction, increased tissue repair and a greater effect on the immune
system. There is debate as to whether or not it is important to obtain a local twitch
response before applying EA. The argument for obtaining deqi is that this would enhance
the therapeutic effect, activating the potential effects of both MA and EA. For many
patients, acupuncture may be a last resort, particularly for those being classified as chronic
pain patients, so obtaining acupunctures effects via electrical stimulation is necessary if
clinical changes are sought quickly and efficiently.
The use of EA can be thought of as a modern scientific extension of acupuncture. As
Woolf (1984, p.679) states: The ability for a clinician to reduce pain in a patient by
exploiting the patients own built-in neurophysiologic mechanisms must rank as one of
modern sciences greatest achievements.
EA also has similarities with TENS. A TENS machine is similar to an EA machine in
that it is a small, battery-operated device that has leads connected to electrodes. The
electrodes are connected to adhesive pads which are placed on the skin, delivering the
electric current. TENS is probably the more frequently used electrotherapy due to it being
non-invasive and easy to administer. EA on the other hand is an invasive procedure which
delivers the current through the skin rather than across it. Mayor (2007) claims that this
has advantages over TENS as EA will need less current to achieve motor stimulation, the
waveform is less distorted and deeper muscle afferents can be stimulated without pain
from cutaneous C-fibres (a cutaneous receptor is a type of sensory receptor found in the
dermis or epidermis). EA, however, will cause a degree of local tissue inflammation due
to its invasive nature, whereas TENS would not.
Common medical conditions that EA has been used to treat include the following.
Relief of acute pain
Musculoskeletal pain
Tendinopathies
Post-operative pain
Labour pain
Dysmenorrhoea
Bone fractures
Dental pain
Relief of chronic pain
Low back pain
Arthritis
Phantom pain
Post-operative pain
Trigeminal neuralgia
Peripheral nerve injuries
Facial pain
Neurological conditions, for example Parkinsons and stroke
Other effects of EA
Modulation of immune, endocrine and circulatory systems
Antiemetic effects, including nausea associated with chemotherapy and morning
sickness
Other improvements useful in MSK conditions
Acceleration of tissue repair by increasing circulation
Increase in blood flow
Increased muscle strengthening
Improved muscle control
Reduction of muscle spasticity
Treatment of denervated muscle compression injuries only
Improved healing of wounds, ulcers and scar tissue
Physiological mechanisms of electroacupuncture
Over the past decades, many studies have suggested various mechanisms of EA; however,
so far no satisfactory consensus has been reached. Moreover, EA has a wide variety of
clinical applications, which in turn make it even more difficult to elucidate the exact
mechanism of action. Nevertheless, a number of researchers have progressively
investigated the physiological mechanisms behind its various applications. To date, pain
management is one of its most thoroughly studied applications (Lee, LaRiccia and
Newberg 2004a, b).
Mechanism of EA in pain control
EA induces its analgesic effects via neuronal mechanisms associated with both the
peripheral nervous system (PNS) and central nervous system (CNS), involving many brain
regions as well as different neurotransmitters and modulators (Hsieh et al. 2000; Lianfang
1987; Pomeranz, Cheng and Law 1977). Studies have hypothesized that a number of
signalling molecules, such as endogenous opioid peptides, cholecystokinin octapeptide,
noradrenalin, serotonin, dopamine, glutamate, -amino-butyric acid and other bioactive
substances, may have direct influence in these mechanisms (Leung 2012; Yoo et al. 2011;
Zhao 2008). In addition, Lin and Chen (2008) postulated that several pain pathways might
be involved, including the hypothalamuspituitaryadrenal (HPA) axis, the autonomic
nervous system (ANS) and the descending inhibitory pathway (hypothalamus
periaqueductal grey arearaphe nucleusspinal cord).
However, scientific evidence for EAs influence on HPA and ANS is still limited;
therefore, this section will particularly concentrate on the neural mechanisms of EA that
have been strongly proposed as possible explanations for its analgesic effects.
Figure 12.1 Schematic diagram of the physiological mechanisms of EA-induced analgesia (derived from Cagnie et al.
2013; Leung 2012; Okada and Kawakita 2009)
Blue arrows = activation; red arrows = inhibition
Scientific research has shown that there is a strong relationship between frequency and
release of endogenous opioids, which play a major role in EA-induced analgesia.
Frequency-dependent EA studies conducted on rats have reported the release of a number
of biochemical substances at different frequencies, such as enkephalin, -endorphin and
endomorphin at 2 Hz (Han 2004); dynorphin at 100 Hz (Han 2003); enkephalin and
dynorphin at 2 and 100 Hz (Zhang et al. 2005b); and substance P (SP) at 10 Hz (Zhang et
al. 2005a).
2 + + +
4 + +
10 +
15 + + +
100 + + +
Adapted from Han 2004; Huang et al. 2004 and Silvrio-Lopes 2011.
Different frequencies and intensities will produce different physiological responses, and it
is important to monitor the patient during an EA treatment and elicit these both verbally
and by observation of the patients response. Low frequency will often produce muscle
twitching and contraction (from the activation of motor neurons). Higher frequencies will
often produce numbness and tingling due to sensory nerve activation and can be a very
pleasant and relaxing sensation, if not slightly unusual. Warmth can signal increased
circulation in an area (Walsh and Berry 2010). From selecting different frequencies,
observing the physical response and monitoring the patient, it is likely that the correct
dose is being administered, resulting in the desired outcome.
Lee (2012) offers some sound practical advice on the use of frequency by using
different combinations of high and low frequencies at different stages of treatment. He
starts with a high frequency to reduce overall pain, with a setting of 100/33 Hz. Once pain
has reduced, he then uses a low frequency of 10/3 Hz to restore normal muscle
functioning.
For an in-depth resource on the use of EA for certain conditions, the reader is
encouraged to consult the companion website to Mayor (2007b). This database presents
clinical studies that have been carried out on EA and other non-traditional acupuncture-
based interventions in a succinct and accessible form.
Waveforms used in EA
Most of the modern EA machines allow the therapist to monitor the intensity and
frequency only, though some devices also allow adjusting the wave formation, which can
have different therapeutic effects. These machines often have a fixed output pulse width
(between 0.2ms and 0.4ms) and waveforms. In EA, however, biphasic square waves are
mostly used, although some machines generate spike or other waveforms (Mayor 2007a).
Some examples of waveforms are shown in Figure 12.3.
A continuous wave is a uniform wave with a constant amplitude and frequency that
therefore does not change over time. It is very similar to what Chinese acupuncturists try
to administer by MA. The advantage of using this waveform in EA is that it is well
tolerated by patients and the stimulus is quickly adapted. However, high intensity may be
required to maximize its therapeutic effects (Mayor 2007b).
An intermittent, or discontinuous, wave flows at irregular intervals and appears on and
off rhythmically. It provides a series of equally spaced pulses but with gaps of inactivity.
Patients also usually adapt to this stimulus (Paraskevaidis et al. 1999).
A densedisperse wave is a combination of two waves (disperse and dense) which
appear alternately, lasting about 1.5s, to prevent the bodys adaptation to the stimulation.
Densedisperse waves provide equally proportioned periods of high- and low-frequency
pulsations. They work at both sensory and motor neuronal levels and stimulate
endogenous pain suppressants (Yang et al. 2007).
Frequency High frequency: 50100 pulses per second Low frequency: 25 pulses per second
Function Inhibits sensory nerves and motor nerves Induces the contraction of muscles
Relieves spasm of the muscles and blood Enhances the tension of muscles and
vessels ligaments
Intensity
In EA, the term intensity usually refers to a measure of current or voltage. The intensity
of the electrical current in acupoints has a distinct effect on the patients physiological
responses, and can be seen in subtle changes (Walsh and Berry 2010). In addition, the
strength of sensation experienced by the patient relies on intensity more than on
frequency.
The majority of devices on the market use an alternating current (AC), since it ensures
more safety for the patient than a direct current (DC). In EA, an AC prevents the build-up
of any electron charge at the points of contact, while a DC can produce excessive heat,
which may cause more pain and discomfort. In general, the order of 12mA (milliamperes)
or 9V (volts) may be the maximum intensity, but these figures may vary significantly
depending on equipment design (Mayor 2007a).
But not too intense
The intensity of stimulus should be the minimum required for the patient to experience its
effect. If the minimum amount results in a painful reaction, the practitioner should provide
adequate care to restrict the muscle twitching to a mild response. The face and areas below
the elbow and knee are highly sensitive to electrical stimulation; therefore, these areas
should be stimulated at a very low intensity. In addition, patients who are taking EA for
the first time should receive MA first, so that suitability and tolerance for EA can be
ensured (Dharmananda 2002).
No pain, no gain?
At no time should there be pain during EA.
The intensity controls should only be increased in minute adjustments, and the
patients response should be monitored with every adjustment. There can be a very small
increase in intensity which will result in a sudden, often painful, response in the patient.
EA machines do not have a linear relationship between their intensity settings and the
amplitude of stimulation; that is, each degree of movement on the intensity dial is not
equivalent to a similar increase in pulse amplitude.
Walsh and Berry (2010) draw attention to the fact that devices can change their
electrical output depending on battery power, with quicker responses occurring with
charged batteries with a relatively low intensity setting, while the same batteries that are
low in power will require a higher intensity setting before achieving the same result.
Longer distances between needles may require a higher intensity when increased
absorption will occur, as energy needs to overcome internal friction that exists in tissue
while travelling through it. However, again closely monitor your patients response when
increasing the intensity.
Safety of electroacupuncture
EA is safe when conducted by a trained practitioner, with relatively low incidence of side
effects (MacPherson et al. 2004). Although some blood-borne diseases such as hepatitis
and HIV have been reported, these are rare, as disposable acupuncture needles are now
widely used. Other adverse reactions reported include broken needles, bleeding, infection,
nerve damage, cardiac tamponade, contact dermatitis and punctures of organs (Lee et al.
2004b).
Researchers have stated that side effects of EA usually occur as a result of bad practice
by a practitioner who has not been properly trained. However, some mild, temporary
reactions may occur in some cases despite proper administration of EA by a qualified
practitioner. These include pain at the point of a needles puncture, bleeding or bruising
from the puncture point, drowsiness, feeling unwell, dizziness or fainting, and worsening
of pre-existing symptoms (Cummings 2011).
Contraindications
According to the World Health Organization (1999), EA should be avoided in the
following conditions:
pacemaker in situ
uterus or pelvic girdle in pregnancy
pregnancy (first trimester)
impaired circulation
severe arterial disease
bleeding disorders
spontaneous bleeding or bruising
undiagnosed fever
unstable diabetes
severe skin lesions
malignant tumours
unstable epilepsy or history of unexplained convulsions
medical emergencies and surgical conditions
needle phobia or overanxiousness.
In addition, needling should be avoided in certain areas of the body. These include:
fontanelle in babies
external genitalia
anterior portion of the neck
broken, fragile, inflamed or infected skin
areas affected by lymphedema
nipples
uterine innervations segment (in pregnant women)
umbilicus
eyeball.
Precautions
Acupuncture needles should not be moved abruptly, since this may result in
displaced or lost needles.
Galvanic current should be used for only a very short period of time.
Electrical current should not be passed through, near or around a fracture.
Appropriate care should be taken if the patient has a compromised lymphatic
system or is immunosuppressed through illness or medication.
Electrical stimulation of needles should be carefully monitored to prevent neural
injury.
Appropriate care should be taken if sensory nerve damage is present.
Special care should be taken in areas that have poor circulation because these areas
often heal poorly and have collateral blood vessels that may bleed.
Careful monitoring must be carried out if the patient has a form of cardiac
arrhythmia, so that this is not aggravated.
EA practitioners should be wary of metal piercings and must not pass current
through metal implants and joints.
Low-frequency stimulation may change original needle position. Cases have been
reported where needles have been further drawn into the body, or forced out, due
to muscle contraction.
Consent and practicalities for EA treatment
The EA practitioner should inform the patient about all treatment options. The
patient should be given clear details of the offered treatment and what it involves.
The patients written informed consent must be documented prior to treatment.
Children (below 16 years of age) should not be treated unless written consent is
taken from a parent or guardian.
The patient must participate in a primary health check-up or complete a checklist
to identify possible contraindications or cautions to treatment.
The EA practitioner should advise the patient to assume a comfortable posture
before needling. The patient should be requested to remain relaxed and not to
change position abruptly during treatment.
The EA practitioner should inform the patient about the possibility of transient
symptoms during and after treatment, including faintness, fatigue, bruising or the
temporary aggravation of symptoms.
The practitioner should inform the patient that, during the needling, he/she may
experience local or distal tingling or sporadic muscle contractions, and that this
is a normal reaction of needling.
The intensity of the stimulation should be carefully monitored. The stimulation
intensity should never reach the level of pain. If it becomes uncomfortable or
painful for the patient, it should be either reduced or stopped, depending on the
severity.
Once the treatment is finished, post-treatment care is recommended. The patient
should be informed that he/she might feel light-headed, stiff and sore for 2448
hours.
Adequate records of all procedures must be kept in a safe and secure manner.
Beginning EA treatment
Needle acupuncture points as chosen.
Attach clips to needles.
Choose frequency and pulse duration on the EA machine.
Ensure the machine is at zero before switching on.
Tell the patient that you are about to begin treatment and that they should inform
you of any sensations felt; it should not be painful.
Slowly turn on intensity and monitor the patient for verbal and non-verbal signs;
monitor throughout treatment and change intensity settings if too strong.
At the end of treatment
Slowly turn down intensity controls to zero.
Switch off the EA machine.
Disconnect all leads, taking care not to stimulate/knock needles.
Remove needles as standard practice and dispose of accordingly.
Check that all needles have been removed.
Inform the patient that all needles have been removed.
Let the patient rest for a few minutes and monitor them as they get up from the
couch.
Clean crocodile clips if necessary and pack away leads for next time.
Inform the patient of any effects of treatment.
Basic EA machine guidelines
Irrespective of the EA/TENS device used, there are a number of important variables that
practitioners should be aware of when setting up their machine for treatment. These
settings include the intensity, frequency and mode of delivery. Basic EA machines are
relatively cheap: a good example is the AWQ-104E Chinese machine, which is small
enough to be portable, has four outputs and has a digital display to depict the frequency of
stimulation during operation. More expensive machines will have more outputs and
greater control over the waveforms used. Generally speaking, though, EA machines will
share the following basic features:
on/off switch
output channels
power source usually a 6 or 9 volt battery
intensity controls for each output
frequency controls two frequency range settings: 0 to 100 and 10 to 999 Hz
(there is often a switch that changes the output by a factor of 10, changing it to a
TENS machine)
densedisperse controls
LocNeedleStimulation treatment and location switch.
Lee (2012) clarifies the confusion surrounding the use of red and black leads on EA
machines. As an alternating current (AC) does not have permanent positive or negative
polarities, and therefore is constantly changing from positive to negative, it doesnt matter
which way round the leads are placed.
Figure 12.5 is a standard EA machine with labels.
Figure 12.5 A standard EA machine
Achilles tendon
The Achilles tendon is covered in depth in Chapter 13. A simple protocol which can be
effective is to use a four-needle cross-pattern technique. Two needles are inserted near the
insertion of the Achilles and the other pair are inserted superiorly to these, still within the
Achilles tendon. The photo below simply shows that the needles are connected diagonally,
with one pair connected to the inferior medial needle and the other to the superior lateral
needle, and vice versa. The red and yellow dotted lines represent the current flowing
through the Achilles.
Inversion sprain
The following points are used:
Gallbladder 40 (anterior and inferior to the external malleolus, in the depression on
the lateral side of the tendon of m. extensor digitorum longus) is paired with non-
acupuncture points anterior to the lateral malleolus between the tibialis anterior
tendon, shown with the red dotted line in the photo below.
Stomach 41 (in the depression at the midpoint of the transverse crease of the ankle
between the tendons m. extensor hallucis longus and digitorum longus) is paired
with Bladder 60 (midway between the high point of the outer ankle bone and the
Achilles tendon), shown with the yellow dotted line in the photo.
This creates a cross-pattern technique across the common ligaments often involved in
inversion sprains.
Knee pain
The following points are used often with osteoarthritis patients:
eyes of the knee (a pair of points in the two depressions, medial and lateral to the
patellar ligament, locating the point with the knee flexed)
Spleen 10
Stomach 33/34.
Create a cross-pattern with the medial eye of the knee point connected to Spleen 10 with
the other eye of the knee point to Stomach 33/34. The red and yellow dots in the photo
below show the current passing through the knee.
Additional points can be used to pass any further current through the knee for a greater
effect, essentially anterior to posterior and medial to lateral. For example:
From Liver 8 to a point of the lateral side anterior to the hamstring tendon.
From Bladder 40 to a point superior to the quadriceps tendon.
Hip pain
Needle the following points:
Gallbladder 30 or a trigger point in the piriformis to a trigger point in the tensor
fasciae latae.
A trigger point below the anterior superior iliac spine (origin of TFL) to a trigger
point located inferior to the greater trochanter on or near Gallbladder 31 in the
iliotibial band or near vastus lateralis. The red and yellow dots in the photo below
represent the flow of current between the points described.
Knuckle and finger joints
Use small needles for this procedure. If in the early stages of trigger finger, then the hand
will have to be palm face-up; otherwise it is preferable for the palm to be face down.
Simply needle either proximal interphalangeal joints or the metacarpophalangeal joints
with a needle inserted either side of the joint, with EA then applied, which passes through
the joint. Ensure that the needles are not touching, as this will create a short circuit. You
can use cotton wool between the needles to stop this from happening.
Neck pain
Needle the following points:
Bladder 10 (in the depression on the lateral aspect of muscle trapezius below the
hairline) to a trigger point in the upper trapezius. Other points can be substituted.
Carpal tunnel
Needle the following points:
Pericardium 8 (in the centre of the palm, between the second and third metacarpal
bones) to Pericardium 5 (between the tendons of m. palmaris longus and m. flexor
carpi radialis), shown with the yellow dotted line in the photo below.
Large Intestine 5 (in the anatomical snuffbox, in the depression between the
tendons extensor pollicis longus and brevis) to Small Intestine 4 (ulnar aspect of
the palm, in the depression between the fifth metacarpal bone and hamate bone),
shown with the red dotted line in the photo.
In addition, palpate for trigger points in the flexor muscles and screen for thoracic outlet
syndrome or cervical dysfunction.
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Chapter 13
There are two important junctions in tendons, the myotendinous and osteotendinous
junctions. The myotendinous junction is a highly specialized anatomic region in the
muscletendon unit where tension generated by muscle fibres is transmitted to the tendon
(Charvet, Ruggiero and Le Guellec 2012). The myotendinous junction is the weakest point
of the muscletendon unit. The osteotendinous junction is where the tendon inserts into a
bone. This junction is where the tendon transmits the force into a rigid bone. These
interfaces also serve to dissipate stress between soft tissue and bone (Khan 2003).
Both intrinsic systems and extrinsic systems provide the main blood supply for
tendons, but this varies from tendon to tendon. The intrinsic system includes both the
myotendinous junction and the osteotendinous junction. The extrinsic system is supplied
via the paratenon or the synovial sheath. The blood supply from the osteotendinous
junction is minimal and limited to the local site of tendon insertion. The myotendinous
junction is richer in its supply than the osteotendinous junction (Sharma and Maffulli
2005).
Tendons have an extremely well-developed anaerobic capacity and low metabolic rate,
which allows them to sustain high loads for long periods. This has the biological
advantage of avoiding ischaemia and early necrosis in these vital structures.
The oxygen consumption by tendons and ligaments is significantly lower than that of
skeletal muscle, often as much as 7.5 times lower, a major disadvantage when factoring
tendons slow healing times. In general, tendon blood flow declines with increasing age
and mechanical loading. Given that tendons require approximately 100 days to synthesize
the main structural proteins, frequent microtrauma during chronic and excessive loading
may not allow sufficient time for tendon repair. Tendon strength is directly correlated with
the collagen amount and is therefore critical in correct functioning.
Different tendons have different properties, with larger tendons being able to withstand
larger forces, whilst longer tendons are able to elongate further before fibril disruption
occurs. Tendons have high mechanical strength and low elasticity. However, these
properties are only maintained when the tendon is elongated, and it has weak resistance to
compressive and shear forces (Selvanetti, Cipolla and Puddu 1997).
Tendon failure
Tendons of certain anatomical locations are more susceptible in individuals who are older,
heavier and male in those genetically predisposed to tendinopathy. Active repair of fatigue
damage must occur, or tendons would weaken and eventually rupture; however, this is an
extremely fine balance between extracellular matrix (ECM) production and degradation.
One current hypothesis is that tendinopathy occurs when tendon cells experience a large
amount of repetitive load (volume, intensity and frequency), resulting in various failed
healing responses as the demands on the tendon are higher than can be managed
adequately with the normal healing response. Xu and Murrell (2008) describe four
cornerstones of tendon histopathology:
1. cellular activation and increase in cell numbers
2. increase in ground substance
3. collagen disarray
4. neovascularization.
Cook and Purdam (2009) propose that there is a continuum of tendon pathology which has
three stages: reactive tendinopathy, tendon disrepair (failed healing) and degenerative
tendinopathy. They maintain that there is continuity throughout the different stages.
The reactive stage is a short-term adaptation to overload that thickens the tendon,
reduces stress and increases stiffness. This stage can be reverted to normal if the overload
is sufficiently reduced or if there is sufficient time between loading sessions. Therefore,
assessment and modification of the intensity, duration, frequency and type of load are the
keys of the clinical intervention (Marchand, OShaughnessy and Descarreaux 2014).
Tendon disrepair describes the failed attempt at tendon healing. There may be an
increase in vascularity and associated neuronal ingrowth. There is a marked increase in
proteoglycan and collagen production. The increase in proteoglycans results in separation
of the collagen and disorganization of the matrix accompanied with neurovascularity of
the tendon. The frequency, volume and length of time over which load has been applied
seem to be important variables in predicting the degree of reversibility, which is still
possible with load management (Marchand et al. 2014).
The final stage of degenerative tendinopathy sees a further disruption of collagen,
widespread cell death and extensive ingrowth of neovessels and nerves into the tendon
substance, leading to an essentially irreversible stage of pathology (McCreesh and Lewis
2013).
The Cook and Purdam (2009) model is widely supported, though the optimal
intervention for each stage of pathology is still unknown. There are many cases where
structure does not parallel pain, therefore the use of imaging is useful. Neal and
Longbottom (2012) suggest that the gold standard should be diagnostic confirmation by
ultrasound because the use of ultrasound scanning is recommended as a way of clinically
differentiating between the phases, with neovessels and a hyperechoic appearance of
collagen fibres being markers of degenerative pathology.
Whilst pain is a driving factor for patients presenting with tendinopathy, and the
eradication of pain often being the clinical goal, determining the source of pain is difficult.
Subjective pain and the correlation of symptoms are often mismatched. Current theories
suggest that the pain arises from biochemical irritants, peritendinous tissues or
neurovascular ingrowth (McCreesh and Lewis 2013). For example, glutamate, a well-
known neurotransmitter and very potent modulator of pain in the central nervous system,
is found in high levels in painful tendons but not in normal tendons (Alfredson and Cook
2007).
Tendon underload
Arnoczky, Lavagnino and Egerbacher (2007) presented an argument for the
mechanobiological under-stimulation of tendon cells, secondary to microtrauma and
isolated collagen fibril damage, as a predisposing factor for the pathological changes
found in tendinopathy. In this proposal, stress deprivation (lack of loading) leads to
upregulation of collagenase expression and apoptosis of tendon cells, leading to decreased
structural and mechanical properties and leaving the tendon capacity unable to tolerate
load. This model is useful when considering tendinopathy in sedentary patient populations
and also active populations who have had a period of rest (off-season or through injury)
and then return to active participation in their chosen sport or activity.
Obesity
Obesity is a worldwide epidemic, and one of the major public health problems in Western
countries. Obesity is a well-recognized risk factor for cardiovascular diseases but is also a
factor in increased susceptibility to musculoskeletal disorders. It is a widely held belief
that tendinopathy is typically due to tendon overload; however, studies suggest that
obesity is a risk factor for tendinopathy and that obese patients often have a poor clinical
outcome both in rehabilitation and surgical procedures. There may be both mechanical and
biochemical reasons for this increased risk. The two hypotheses for the two different
mechanisms are the increased yield on the load-bearing tendons and the biochemical
alterations attributed to systemic dysmetabolic factors (Nantel, Mathieu and Prince 2011).
Obese individuals have also been shown to modify the force alignment and
consequently the distribution of forces at the knee during weight-bearing. In adults, an
increased bodyweight leads to major modifications in the gait pattern. Obese individuals
have been shown to walk with a shorter step length, lower cadence and velocity, a
decrease in the duration of the simple support phase and an increased double support
phase. The increase in load when combined with shear and compressive forces may
increase susceptibility to tendinopathy (Nantel et al. 2011).
Typically, obese patients have a chronic low-grade inflammatory state. As a
consequence, Abate (2014, p.37) claims that the release of profibrotic factors, such as
TGF-, is reduced, and this may have a detrimental effect on tendon healing, especially if
the production of type I and III collagen is also reduced. The main histopathologic
findings are a relative paucity of small collagen fibrils, expression of an impaired
remodelling process, deposition of lipid droplets which can abut to tendolipomatosis, and
a disorganized architecture in the tension regions. Both load-bearing and non-load-
bearing tendons can be affected. Because thin fibres confer greater elasticity to tendons,
their relative scarcity could be responsible for increased stiffness and microruptures as a
consequence of excessive loads (Abate 2014).
Generally, obese patients are encouraged to participate in some form of physical
activity to reduce weight and associated health risks. However, this should be graded, and
attention to weight-bearing activities should be introduced gradually or substituted for
non-weight-bearing activities because obese patients may have tendons with subclinical
damage, and overload can easily reach the symptomatic threshold, signalling the start of
tendinopathy and possibly preventing any further physical activity.
Use of acupuncture
Borchers, Krey and McCamey (2015) conducted a systemic review on tendon needling for
treatment of tendinopathy and concluded that tendon needling improves patient-reported
outcome measures in patients. However, only four studies met the inclusion criteria. This
highlights the need for high-quality research-based evidence to determine acupunctures
potential use in treating tendinopathies.
Neal and Longbottom (2012, p.346) echo these findings: We would suggest that there
is a small but high quality contingent of evidence supporting the theory that acupuncture
may be able to influence tendon healing by increasing blood flow via local vasodilation
and increasing collagen proliferation. These effects are most likely a result of an increase
of the neuropeptide CGRP from sensory nerve endings and an increase in mechanical
signalling through the extracellular matrix respectively. However, the absence of evidence
does not mean that acupuncture is unable to effect tendon healing it just hasnt been
proven effective or ineffective yet.
It is now well documented that acupuncture performed at local sites releases powerful
vasodilators, but more research in healthy and pathological human tendon tissue would be
required to further support this theory. Kubo et al. (2010) found that acupuncture on
tendons increased the blood volume and oxygen saturation of the tendon and that this was
maintained post-acupuncture. By increasing blood flow, oxygenation and tissue healing
can occur in the tendon. Supporting the intrinsic healing of tendons (through acupuncture
or other means) will result in better biomechanical remodelling of the tendon.
When considering Cook and Purdams (2009) tendinopathy continuum model, it is
important to establish the effects of acupunctures role in treating tendinopathies and to
establish the stage or stages at which the most beneficial effects may be achieved.
De Almeida et al. (2014) hypothesized that acupuncture can modulate both anti-
inflammatory (AI) and mechanotransduction (MT) molecular pathways. The modulation
of these pathways can increase type I collagen synthesis and subsequent reorganization,
allowing an increase in the load-bearing capacity of the tendon.
The addition of electroacupuncture to treatment protocols may have an additional
benefit. De Almeida, De Freitas and De Oliveira (2015) found that when using EA it
resulted in an increase in collagen fibril diameter and reorganization potential for
increased synthesis and reorganization of type I collagen, which is the major tendon
structural component (approximately 95% of the total collagen). Inoue et al. (2015, p.60)
concluded: Our key findings were that the application of EA [electroacupuncture] to a
tendon rupture model increased total cell counts, TGF-1 and b-FGF positive cell counts,
and also the mechanical strength of repaired tendon compared with control groups
receiving MA [manual acupuncture] or no treatment. Both of these were animal studies,
and need to be replicated in human studies, both healthy and pathological, to confirm the
hypothesis.
There is further speculation that acupuncture may result in reduction in mechanical
hypersensitivity through effects on neurotransmitters, neurotrophin expression and
neuromodulation (Speed 2015).
The use of segmental acupuncture may be of further benefit to tendon healing.
Acupuncture when applied segmentally can inhibit the pre-synaptic release of glutamate, a
nociceptive neurotransmitter consistently seen in degenerative tendons (Zhao 2008).
It is well documented that glutamate and its receptors play a pivotal role in the spinal
transmission of nociceptive information and central sensitization in physiological and
pathological conditions. EA may further enhance this effect when applied segmentally.
Key points
Currently only small, though high-quality, studies have been carried out to support
acupuncture for tendon healing.
Vasodilators are released when needling local points and further increased by
choosing points in or near myotendinous and osteotendinous junctions.
Acupuncture results in increased collagen reorganization.
The above points lead to reduced pain and increased loading capacity.
Periosteal pecking may be beneficial (see below).
Acupuncture results in reduction in central sensitization.
EA may have significant benefit over MA.
Combining acupuncture into manual therapy and exercise therapy may result in
improved patient outcome compared with acupuncture as a stand-alone therapy.
Possible acupuncture protocols
Acupuncture can be used as a stand-alone therapy or as a component of a combination of
therapies. There is no standard acupuncture treatment for tendinopathy; rather, there are a
number of possibilities. These may include the following:
crossing-pattern technique using four needles across a joint
selecting points near myotendinous and osteotendinous junctions
direct needling of tendon
thread needling along tendon
use of local, distal and adjacent TCM points (yuan, jing well, shu stream, he sea)
layering effect (local, supraspinal and segmental points)
periosteal pecking
surrounding dragon technique (needle circling)
use of EA.
Periosteal pecking
Periosteal pecking (sometimes referred to as osteoacupuncture) is a form of acupuncture
in which the tip of the needle contacts the periosteum. When one hits the bone with the tip
of the needle, the needle is used to peck the bone. The same place of periosteum is not
pecked repeatedly but the tip is moved around a small distance to peck a larger area (Mann
2000). The area that is pecked is typically around 0.250.5 inches in diameter, and is
pecked 24 times per second for between 10 and 30 seconds. Patients usually experience
some deqi, and the needles are left in for between 10 and 30 minutes without further
stimulation (unless EA is applied).
The success of periosteal pecking in comparison with other modalities warrants further
investigation, especially when combined with manual acupuncture or electroacupuncture.
It seems plausible that combining periosteal pecking, MA and EA will have increased
benefits. In an experimental study in healthy volunteers, electrical stimulation of the
periosteum was superior to stimulation of musculature and skin in alleviating pain
originating from the periosteum and musculature (Hansson, Carlsson and Olsson 2008).
The technique can be painful, as the periosteum has nociceptive nerve endings,
making it very sensitive to stimulation. Therefore consideration of toleration of pain levels
versus clinical outcome may be required when considering using this technique.
Clinical trials and literature on the use of periosteal pecking are sparse, but the
treatment has been used in the treatment of shin splints, osteoarthritis of the knee and hip,
cervical disorders and other MSK conditions.
Techniques
Achilles tendon
The Achilles tendon attaches the posterior calf muscles the gastrocnemius and soleus
to the calcaneus. Its action is to actively plantar flex the ankle, and to resist dorsiflexion.
There is a bursa interposed between the anterior surface of the tendon and the surface of
the calcaneus.
Fahlstrm et al. (2003) found that Achilles tendinopathy accounts for 617 per cent of all
running injuries among recreational runners, and the incidence is higher with older age
and male gender. The peak age for Achilles rupture is 3040, when degenerative changes
and continued or occasional high stress from sports combine.
There are two main tendinopathies mid-portion Achilles tendinopathy and
insertional tendinopathy, with mid-portion being more frequent. The mid-portion
tendinopathy is roughly 12.5 inches above the insertion point of the Achilles tendon on
the calcaneus and is an area of diminished blood supply, leaving it susceptible to injury.
Insertional tendinopathy affects the insertion of the tendon on the calcaneus, comprising
around 25 per cent of cases compared with 75 per cent of cases of mid-portion
tendinopathy (BMJ 2012).
Generally, the initial treatment consists of a multifactorial approach that may include a
combination of rest (complete or modified activity), medication (NSAIDs,
corticosteroids), orthotic treatment (heel lift, change of shoes, corrections of
malalignments), stretching and strength training. If conservative treatment fails, surgical
treatment is instituted (Alfredson and Cook 2007).
Herringbone technique
For mid-portion Achilles tendinopathy, the herringbone technique is recommended. This
method has recently been adopted by acupuncturists and is referred to as the herringbone
technique because of its appearance. The configuration is achieved by inserting needles
vertically, medially and laterally (i.e. parallel) to the tendon. The herringbone technique is
mainly used in the Achilles tendon because of its accessibility, and is taught on
acupuncture courses (Kishmishian, Selfe and Richards 2012). A possible standardization
of the technique is to have four needles for each surface (vertically, medially and laterally)
and equal distance from each other. The needle penetrates the tendon to a depth of around
0.2 inches (though measurements only serve as a guide, as there are differences from
patient to patient). Additional needling of the soleus and gatrocnemius (posterior chain)
may be beneficial, points such as Bladder 58, 57, 56 and 55, inner/outer bladder points and
huatuojiaji points. EA can be applied in a cross-pattern and along the vertical portion of
the tendon using an additional pair.
For insertional tendinopathy, the herringbone technique can be used with the addition
of periosteal pecking into the calcaneal insertion.
Acupuncture
Needling around the medial epicondyle must be done with caution due to the close
proximity of the ulnar nerve. Search for trigger points in all of the flexors, as this may
cause or contribute to ulnar compressive neuropathy and degrade the tendon due to
excessive force placed on the tendon. The technique is the same as for tennis elbow.
Needle the worst one-to-four points around the epicondyle with or without periosteal
pecking. Use EA across the joint or along the flexor group for stimulation of a wider area.
Acupuncture
Palpate for the ischial tuberosity. This can be needled directly, and periosteal pecking can
be applied. The needle can be left in or withdrawn. A cross-pattern technique can then be
applied with four needles. Each needle is roughly 0.51 inch from the ischial tuberosity
and placed superior, inferior, medial and lateral to the ischial tuberosity. The needles can
be angled towards the tuberosity into the fibrous mass of the tendon. EA can then be
applied from superior to inferior and medial to lateral. Palpate for trigger points in the
hamstrings, gluteus and piriformis, and needle if appropriate. Segmental points can be
added at the levels of L-4/L-5, and EA can be applied.
Patellar tendinopathy
Chronic patellar tendon conditions, also known as patellar tendinosis or jumpers knee,
are numerous in elite athletes who run and jump. The posterior proximal patellar tendon is
subjected to greater tensile tendinous forces as compared with the anterior region,
especially with jumping activities (Rutland et al. 2010).
The patellar tendon, the extension of the common tendon of insertion of the quadriceps
femoris muscle, extends from the inferior pole of the patella to the tibial tuberosity (Khan
et al. 1998). The microtrauma to the posterior proximal patellar tendon or overuse injury
develops from repetitive mechanical loading of the tendon, typically through excessive
jumping and landing activity. As with all tendons, any major changes in frequency and/or
intensity of training may also lead to overuse and overload of the tendon (Rutland et al.
2010). In addition, other factors may have an impact, such as quick acceleration and
deceleration, stopping and sudden rotation, causing compressive and shear forces on the
tendon.
The blood supply has been postulated to contribute to patellar tendinopathy; however, at
rest it has a well-vascularized blood supply which may suddenly be reduced during
physical activity. The patellar tendon receives its blood supply through the anastomotic
ring, which lies in the thin layers of loose connective tissue covering the dense fibrous
expansion of the rectus femoris (Khan et al. 1998). Needling into this area will help blood
flow into the tendon.
Physical examination should look for pain at the tendon insertion, and any thickness
should be noted. Additional functional tests such as single leg squats should be performed,
and jumping tests should be used as provocation tests.
Treatment for patellar tendinopathy often includes stretching of lower limb muscles,
deep friction massage across the patellar tendon and eccentric quadriceps exercises.
Acupuncture can be utilized as part of this conservative programme.
Acupuncture
Needle the following points:
eyes of the knee
Stomach 36
Spleen 9.
Retain for between 20 and 30 minutes. EA can be applied to create a cross-pattern
diagonally across the patella tendon.
Additional points to needle to add to the suggested protocol are Stomach 34 and
Spleen 10.
De Quervains
De Quervains stenosing tenosynovitis is a disorder that is characterized by wrist pain and
tenderness at the radial styloid. It is caused by impaired gliding of the tendons of the
abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles. These
musculotendinous units control the position and orientation, force application and joint
stability of the thumb. The impaired gliding is believed to be as a result of thickening of
the extensor retinaculum at the first dorsal (extensor) compartment of the wrist, with
subsequent narrowing at the fibro-osseous canal (Papa 2012).
Figure 13.9 De Quervains Syndrome
Acupuncture
Thread needle along the tendons of the thumb. Thread needle lateral to the extensor
pollicis longus, then needle lateral to the abductor pollicis longus. Needle two other
points: a trigger point near the styloid process, and another near or on Large Intestine 6.
EA can be applied to create a cross-pattern diagonally that runs across the tendon.
Plantar fasciitis
The plantar fascia is a band of fibrous tissue that originates from the medial tubercle of the
calcaneus and stretches to the proximal phalanx of each toe. It is the main stabilizer of the
medial arch of the foot against ground reactive forces, and is instrumental in reconfiguring
the foot into a rigid platform before toe-off. Sudden changes in the intensity, duration and
frequency of loading the lower limb may overload the supporting structures of the lower
extremity, eventually leading to injury (Dubin 2007).
Figure 13.10 Plantar fascia
If shortened calf muscles are part of the clinical picture, then needling these muscles can
be included in the treatment plan (e.g. Bladder 55/56/57/58).
Tibialis posterior syndrome
Kirby (2000, p.2) describes the anatomy of the tibialis tendon as:
originating from the posterior aspects of the tibia, fibula, and interosseous membrane
as the deepest muscle in the deep posterior compartment of the leg. The posterior
tendon passes posterior to the medial malleolus within the confines of the flexor
retinaculum, just slightly posterior to the ankle joint axis. As the tendon continues
inferior to the medial malleolus, it passes medial and plantar to the subtalar joint axis
and plantar to the oblique midtarsal joint axis. Just posterior to the navicular
tuberosity, the tendon divides into three components: anterior, middle, and posterior.
The anterior component is the largest of the tendon components, sending insertions to
the navicular tuberosity and plantar aspect of the first cuneiform. The middle
component inserts deeply in the plantar arch of the foot onto the second and third
cuneiforms, the cuboid, and onto the bases of the second through fifth metatarsals (the
fifth metatarsal insertion is sometimes absent). The posterior component branches
laterally and posteriorly and inserts onto the anterior aspect of the sustentaculum tali.
The tibialis posterior tendon is the primary dynamic stabilizer of the medial longitudinal
arch. Its contraction results in inversion and plantar flexion of the foot and serves to
elevate the medial longitudinal arch, which locks the mid-tarsal bones, making the hind
foot and midfoot rigid (Kohls-Gatzoulis et al. 2004).
It has been proposed that the tibialis posterior tendon becomes fibrotic through a
process of repeated microtrauma. In addition, a poor blood supply to the tendon has been
identified as it courses posterior to the medial malleolus, leaving it susceptible to
regeneration in that area. A growing body of research proposes that abnormal forces arise
from even mild flatfootedness, resulting in lifelong greater mechanical demands on the
tibialis posterior than in a normal foot. Most people who develop the condition already
have flat feet (Kohls-Gatzoulis et al. 2004). With overuse or continuous loading, a change
occurs where the arch begins to flatten more than before, with pain and swelling
developing on the inside of the ankle. Inadequate support from footwear may occasionally
be a contributing factor. Other factors include trauma or injury to the lower limb, and
occasionally this condition may be due to fracture, sprain or a direct blow to the tendon.
The risk of developing posterior tibial tendon dysfunction increases with age, and research
has suggested that middle-aged women are more commonly affected.
Typically, tibialis posterior tendinopathy is classified into four stages:
Stage 1. Medial malleolus pain and swelling along the tendon. The patient is able
to stand on tiptoe on one leg and is usually treated with insoles and manual
therapy. In the later stages the patient will have developed an acquired flatfoot
deformity.
Stage 2. The patient will have more pain and swelling than in Stage 1, with
increased flattening of the foot and decreased power in the tendon. Tendon
reconstruction is necessary if conservative treatment fails.
Stage 3. A degree of deformity at the subtalar joint is found on X-ray. It may be
treated with the use of orthoses. A fusion of the hind foot may be necessary.
Stage 4. Accompanying ankle deformity. Surgery to the ankle may be necessary.
In Stage 1 of tibialis posterior dysfunction, the signs are of swelling and tenderness behind
and below the medial malleolus (along the course of the tendon), and some weakness or
pain with inversion of the foot. The patient may have some difficulty rising on one heel
only, or weakness after multiple heel rises.
When palpating along the tibialis posterior tendon, look for swelling, signs of
deformity and pain on palpation, all of which are signs of dysfunction. Other tests include
visual inspection of the foot (looking for heel alignment and flat foot) and testing the
tendon for power (with posterior tibial dysfunction, the posterior tibial muscle contraction
is unable to generate adequate tensile forces in the posterior tibial tendon). A functional
test is to ask the patient to perform ten heel raises (patients with tibialis posterior
dysfunction will not be able to do this).
Acupuncture
Acupuncture may be of use in tendon regeneration and pain reduction primarily in Stages
1 and 2 alongside conservative management. In Stages 3 and 4 its use is mainly for pain
management. Use the suggested points below to create a cross-pattern and to increase
blood flow to the tendon:
Kidney 2 to Kidney 7
Spleen 4 to Spleen 6.
EA can be applied to stimulate a greater area across the tendon from Kidney 2 to Kidney 7
and from Spleen 4 to Spleen 6. Check for trigger points in the peroneals and lateral leg
muscles.
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Subject Index
abdominal palpation 2930
acetylcholine (ACh) 42, 46
Achilles tendon 2845
EA techniques 266
herringbone technique 286
and high-impact exercise 275
percutaneous tenotomy and acupuncture scraping technique 2867
active trigger points 402
acupuncture
advantages of using 8
adverse effects of 1228
critical views of 1011, 28
definition 9
derivation of term 60
different forms and techniques 1001
impact on medical trials 1012
effectiveness and efficacy
evidence for 10612
science and complications of 1026
exponential growth in worldwide practice 8
history of 1315, 33
autopsy 17
clinical and empirical experience 19
development in Japan 2831
development in modern China 258
early massage 1517
moxibustion 234
needle development 245
as one of oldest forms of alternative medicine 60
origins 60, 96
philosophy 1920
pre-historic 323
qi gong, tai chi and martial arts 1819
spread to Western world 312
surgery 1718
TCM basic principles 202
inconclusivity of models 867
integrating 1011
mechanism in pain control 63
layering method 701
need for more research into 72
neurophysical 648
placebo effect 712
unknown 6970
medical uses of 1212
NICE recommendations 967
for pain relief and control 1026, 121
procedure 1201
psychosocial effects 1046, 113
regarded
as form of complementary medicine 120
as fundamental discipline of TCM 60
as part of conventional medicine 9
as part of wider therapy approach 89
as unique among fascial therapies 92
relation to qi 60, 96, 120
research problems 978, 113
safety 121, 123, 125
with difficult and dangerous acupoints 134
guidelines for monitoring of accidents and untoward reactions 1258
and regulation 12834
risk factors 135
scraping technique 2867
STRICTA guidelines 989
tendinopathy use 2813
see also individual tendon disorders
training routes 9
unifying theories of
channel system 779
connective tissue hypothesis 80
embryology 857
fascia classification 813
growth control model 879
holistic communication system 7980, 92
introduction 767
piezoelectricity 835
study conclusion 923
systems biology 902
see also traditional Chinese medicine (TCM)
acupuncture channels see channels
acupuncture points see points
adaptations see individual muscles
adductor muscle 2245
alpha motoneurons 49, 656
articular dysfunction 489, 1423
ATP 43
autoimmune diseases 57
autonomic nervous system (ANS)
affected by nerve impingement 46
disturbances 523
evidence for EAs influence on 249
linked with fascia system 82
autopsy, historical 17
biceps brachii muscle 1789
biceps femoris muscle 22831
bioelectromagnetism 83
bleeding 126
blind practitioners 2930
blood-borne viruses (BBVs) 124, 1278, 258
bloodletting 16, 24
bone 834, 2757
British Medical Acupuncture Society (BMAS) 32, 96, 128
broken needles 127
cancer pain 112
carpal tunnel syndrome
acupuncture supported by controlled trials 122
EA techniques 2701
nerve involvement 57
cellular connections 812, 88
central mechanisms of acupuncture
diffuse noxious inhibitory control theory 68
endogenous opioid theory 67
serotonergic and noradrenergic descending inhibitory pathway theories 68
central pain modulation 623
central sensitization see sensitization
cervical multifidus muscle 202
channels
compared to fascial planes of West 93
conduction of electricity 84
and growth control model 879, 93
lack of evidence for 22
main 21
palpation 28, 1456
points grouped into system of 201
possibility of anatomical basis for 767
and qi gong 1819
system 779
Chapmans points 144
China (modern), acupuncture development in 258
chronic pain
causal factors 143
central sensitization 63, 252
clinics, use of acupuncture 8
deep needling with deqi 152
defying compartmentalization 104
EA for relief of 246, 248
evidence for acupunctures effectiveness 108, 11112
high incidence in neck and shoulder 51
and radiculopathy 458
clinical and empirical experience, historical 19
clinical implications see individual muscles
clinical reasoning approach 701
Cochrane reviews 102, 1067, 10912
collagen fibres 84, 88, 152, 275, 279
Compendium of Materia Medica 14
complex regional pain syndrome 51
conductivity 84, 89
connective tissue
and acupuncture point sites 80
disorders 57, 274
epitenon and paratenon 276
fibroblasts 152
hypothesis 80
interstitial 80, 144
and needle grasp 145, 151
see also fascia
coracobrachialis muscle 177
Cultural Revolution 267, 246
current intensity 2578
De Quervains stenosing tenosynovitis 2978
deep fascia 801
deltoid muscle 1623
deqi
definition 148
dispute over importance 1489
EA argument for obtaining 246
evidence for 152
as experienced by patient 149
factors influencing 149
mechanisms of action 1512
in periosteal pecking 284
practical considerations 1501
relationship with local twitch response 45, 148
response 99, 143
transfer of mechanical signals 845
dermatome 467
descending pain control system 63
descending pain inhibitory pathways 64, 68
diagnostic scans 138
diffuse noxious inhibitory control theory (DNIC) 64, 68
dim mak 19
disease
autoimmune 57
blood-borne 124, 1278, 258
early diagnostics 16
early recording 14
and reductionism 901, 93
disharmony, pattern of 22, 92
dit dar 19
drowsiness 127
dry needling
vs. acupuncture 1002, 106, 148
as adaptation of traditional acupuncture 61
adverse effects of 1225
critical view of 10
definitions 9, 100
differentiated
from myofascial trigger point injections 910
from TCM 120
introduction to 1201
as part of conventional medicine 61
primarily used to alleviate pain 61
safety and regulation of 12834
as Western medical acupuncture 910, 61
see also acupuncture
duty of care 1301
EA see electroacupuncture (EA)
ECM see extracellular matrix (ECM)
effectiveness and efficacy
evidence for 97, 106
cancer pain 112
knee osteoarthritis 11011, 123
low back pain 1068, 113, 123
migraines and chronic head pain 11112
neck pain 109
shoulder pain 10910
science and complications of 1026
electroacupuncture (EA)
benefits over manual acupuncture 246
common medical conditions treated 247
contraindications 25960
definition 245
frequency 2535
function 246
habituation and sensitization 252
history of use 2456
improvements in MSK conditions 248
intensity of current 2578
introduction to 245
mechanism in pain control 24950
endorphins theory 251
gate control theory 2501
noradrenalin theory 252
serotonin theory 2512
as modern scientific extension of acupuncture 247
other uses 248
parameters of 253
physiological mechanisms 249
precautions 2601
for relief of chronic pain 248
safety of 2589
similarities with TENS 247
technique
Achilles tendon 266
carpal tunnel syndrome 2701
hip pain 2689
inversion sprain 267
knee pain 2678
knuckle and finger joints 269
low back pain 2656
neck pain 270
treatment
beginning 262
consent and practicalities for 2612
ending 262
frequency 265
machine guidelines 2634
needle placement for 2645
waveforms used in 2557
embryology 857
endogenous opioid peptides
release of 67
role in acupuncture-induced analgesia 67
as signalling molecules 249
endogenous opioids
acupuncture stimulating release of 103
antinociceptive 103
relationship between frequency and release of 254
system 62, 64, 71
theory 67
endorphins theory 251
energy crisis 43, 56
equipment
disposal 1323
recommendations 12930
extensor carpi radialis brevis 21011
extensor carpi radialis longus 21011
extensor carpi ulnaris 21011
extensor digitorum 21011
extracellular matrix (ECM) 7980, 84, 878, 2756, 278, 281
fainting 1256
fascia
classification 813
converting mechanical stress 84
ECM as primitive 87
functions 80
good conductor and generator of electricity 85
longitudinal and transversal space 21
as mediator of information 82
as missing link for cross-system integration 79
palpation considerations 1446
plantar 274, 299300
research into role of 767, 83
resembling silk 78
role in force transmission 80
as soft tissue component of connective tissue system 80
system
as holistic communication system 7980, 92
possessing high degree of plasticity 92
see also myofascial entries
flexor carpi radialis 2068
flexor carpi ulnaris 2068
flexor digitorum profundus 2067, 209
flexor digitorum superficialis 2067, 209
flexor pollicis longus 2067, 209
force transmission 80
frequency (cycles) 2535
gastrocnemius muscle 2346
gate control theory 2501
gluteus maximus, gluteus medius and gluteus minimus muscles 21618
golfers elbow 2913
gracilis muscle 226
growth control model 879
growth hormone deficiency 567
habituation 252
hamstring injury 229, 2935
hamstring muscle group 22831
health and safety, commitment to 134
herbal medicine 1314, 16, 25, 278
herringbone technique 286
high hamstring tendinopathy (HHT) 2935
high-throughput screening 90
hip pain 2689
holistic communication system 7980, 92
home visits 133
homeostasis 82, 85, 92
hormonal dysfunction 56
Huang Di Nei Jing 17, 23, 78, 89
hyperalgesia 41, 489
Illustrations of Channels and Points 28
infraspinatus muscle 1601
integrated trigger points hypothesis 423
interoception 82
Intramuscular Stimulation (IMS) 46, 70
inversion sprain 267
iron deficiency 56
Japan
acupuncture development in 2831
banning acupuncture and moxibustion 24
needles, smaller and highly polished 150
shallow needle insertion 29, 1001, 151
jing 21, 78
joint dysfunction 489
joint involvement 57
Kissinger, Henry A. 32
knee, jumpers 2957
knee osteoarthritis
acupuncture point for 91
acupuncture supported by controlled trials 121
EA techniques 2678
evidence for acupunctures effectiveness 11011, 123
knuckle and finger joints 269
latent trigger points 402, 50
lateral epicondylitis (tennis elbow) 28991
latissimus dorsi muscle 16870
Law of Denervation 46, 70
layering method 701
levator scapula muscle 1889
local twitch response (LTR) 40, 45, 66, 148, 168, 246
see also deqi
low back pain
acupuncture supported by controlled trials 121
EA techniques 2656
evidence for acupunctures effectiveness 1068, 113, 123
NICE recommendations 96, 122
lumbar erector spinae muscle 203
luo 21, 78
Lyme disease 57
magnesium deficiency 56
mai 21, 78
Mao, Chairman 256
martial arts 13, 19, 85
massage
for blind practitioners 2930
deep friction 275, 296
early 1517
Massage of Lao Zi 1516
masseter muscle 1823
mechanical stress 834, 86, 145
mechanoreceptors 67, 82
mechanotransduction 845, 282
medial epicondylitis (golfers elbow) 2913
medical trials 97, 1012
conditions supported by controlled 1212
for effectiveness and efficacy 10413
meridian-based acupuncture
connecting function 144
distinguished from dry needling 1001
and EA 264
mapping pathways onto nervous system 103
meridians located along fascial planes 144
see also myofascial meridians
migraines
evidence for acupunctures effectiveness 11112
NICE recommendations 96, 122
motor output 66
moxibustion 234, 28, 31, 78
MTrPs see myofascial trigger points (MTrPs)
mugwort 234
muscle contraction 42, 46, 261
muscle involvement 57
musculoskeletal (MSK) conditions
articular dysfunction as major category of 48
EA for 2478
as most common reason for seeking acupuncture care 8
and myofascial meridians 145
and obesity 280
pain
and MTrPs 367
and vitamin D 546
palpation of 138
PSB model to ascertain causes of 54
tui na for 1415
myofascial meridians 1445, 264
myofascial pain
articular and joint dysfunction 489
autonomous nervous system disturbances 523
as caused by painful trigger points 36
chronic, and radiculopathy 458, 143
as condition for which acupuncture is supported by controlled trials 121
definition 38
dry needling for 61, 100
early observations 378
muscle contraction 42
non-structural perpetuating factors 547
peripheral and central sensitization 4952
peripheral neuropathy model 6970
reasons for therapy failure 58
systematic review findings 123
trigger point concept 37
myofascial trigger points (MTrPs)
as cause of musculoskeletal pain 36
as cause of myofascial pain 36
clinical presentation 412
complex 40
concept of 37
definition 3840
high correspondence to acupuncture points 86
hypothesis of integrated 423
injections 910
local twitch response 45
locating 435
systematic review findings 123
National Institute for Health and Care Excellence (NICE) 967, 106, 108, 112, 122
neck pain
EA techniques 270
evidence for acupunctures effectiveness 109
origin of acupuncture needles 1617
needle grasp 845, 145, 14951
needle shock 126
needles
broken 127
development 245
origins of use 1617
percutaneous injury 127
stuck 127
needling sensations 14852
needling techniques see individual muscles; individual tendon disorders
nerve impingement 46, 222
nerve involvement 57
nociception, nociceptors and nociceptive input 45, 4951, 56, 612, 646, 689, 82, 143, 252
non-structural perpetuating factors 547
noradrenalin theory 252
noradrenergic mechanisms 64, 68, 252
obesity 2801
obturator muscle 219
organizing centres 889
organs
channels associated with 778
embryological relationships 89
fascia enveloping 801
fascial system as 83
historical knowledge of 17
and pain 53
punctures of 2589
relation to tongue 23
in TCM 212
Otzi 323
pain
control
effectiveness and efficacy 10212
mechanism of acupuncture in 6371
mechanism of EA in 24952
placebo analgesia 712
modulation of perception
central 623
chronic 63
peripheral 62
physiology of 61
pain referral patterns see individual muscles
pain, types of see chronic pain; complex regional pain syndrome; myofascial pain; referred pain; visceral pain
palpation
abdominal 2930
acronyms 140
applicators 141
channels 28, 1456
Chapmans points, TCM alarm and associated points 144
depth of pressure 1412
fascial considerations 1446
faulty posture 142
as having educational role 139
as important diagnostic tool 30, 139
as important therapist skill 44, 138
introduction to 1389
of MTrPs 445
of paraspinal muscles 47, 1423
practitioner positioning 142
radiculopathy model 143
sensitivity to patients 139
snapping 445
static and motion 141
structure and function 1423
technique 13941
see also individual muscles
paraspinal shortening 46
patellar tendinopathy 2957
pectoralis minor muscle 1746
percutaneous injury 127
percutaneous tenotomy 2867
periosteal pecking 284
peripheral mechanisms of acupuncture 645
peripheral neuropathy 6970
peripheral pain modulation 62
peripheral sensitization see sensitization
peroneal muscles 2401
personal safety 132
philosophy 1920
piezoelectricity 835, 93
piriformis muscle 2223
placebo analgesia 64, 712
placebo effect 97, 1012, 1057, 113, 123
plantar fasciitis 299300
plantaris muscle 2389
points
for carpal tunnel 2701
Chapmans 144
and connective tissue 80
correlation with fascial septa 76
for De Quervains Syndrome 298
as dynamic, living structures 92
early discoveries about 16
electrical properties 84
electrical stimulation of 246, 257, 264
embryological relationships 89
and embryology 857
end-product of millions of observations 19
for golfers elbow 292
grouped into channels 201
for hamstring injury 2945
having length, width and depth 31
in herringbone technique 286
high correspondence to trigger points 86
for hip pain 2689
for inversion sprain 267
for knee pain 2678
layering method 701
methods for locating 141
moxa for burning on 234
for neck pain 270
needle techniques 1201, 145, 150, 152
and organizing centres 889
for patellar tendinopathy 297
peripheral stimulation of 67
piezoelectric effect at 85
precautions with difficult and dangerous 134
for promoting homeostasis 92
protocols 283
as remnants of growth control system 87
segmental 656, 701
supraspinatus 2889
tattoos corresponding too 33
for tennis elbow 291
terminology 31
for tibialis posterior syndrome 303
use in martial arts 19
varying effects of stimulating 867, 89
and vasodilators 283
see also myofascial trigger points; trigger points
popliteus muscle 2323
postural-structural-biomechanical (PSB) model 54
posture, faulty 142
practitioner responsibility 1312
pre-historic acupuncture 323
pronator teres muscle 214
proprioception 82, 142
psychosocial effects 1046, 113
pulse diagnosis 22, 31
qi 212, 601, 78, 93, 96, 120
see also deqi
qi gong 13, 1819, 78
qi-passage 21
quadratus lumborum muscle 2001
radiculopathy 458, 6970, 143
randomly controlled trials (RCTs) 1012, 1045, 10710, 113
records maintenance 134
rectus femoris muscle 171
reductionism 901
referred pain 378, 401, 44, 50, 53, 139, 172, 216, 228
Reston, James 32
rhomboid major and minor muscles 1989
risk factors 135
Ryodoraku channels 84
safety
of acupuncture 121, 123, 1258, 1345
of dry needling 12834
of EA 25861
sarcomeres 423
sartorius muscle 227
scalene muscles 2045
scraping technique 2867
segmental dysfunction 689
segmental inhibition 62, 64, 66, 103
segmental mechanisms of acupuncture
of EA 2501
motor output, changes in 66
nociceptive input, inhibition of 656
sympathetic outflow, alterations in 66
semimembranosus muscle 2301
semitendinosus muscle 2301
sensitivity of patient 154
sensitization
central
acupuncture for 283
detecting hypersensitivity 52
modulation of 63
response characteristics 49
role of glutamate and receptors 282
theory 501
in EA 252
peripheral
detecting hypersensitivity 52
modulation of 62
response characteristics 49
theory 50
serotonergic mechanisms 64, 68, 2512
serotonin theory 2512
serratus anterior muscle 215
sham acupuncture 72, 97, 99, 101, 10313, 123
shoulder pain
acupuncture supported by controlled trials 121
evidence for acupunctures effectiveness 10910
soleus muscle 2345, 237
splenius capitis and cervicis muscles 1901
Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) guidelines 989
sternocleidomastoid muscle 1945
suboccipital muscles 1923
subscapularis muscle 1645
superficial fascia 81
supinator muscle 21213
supraspinatus muscle 1589
supraspinatus tendon 2879
surgery
EA devices in 2456
history of 1718
sympathetic outflow 66, 71
systems biology 903
tai chi 13, 78, 85
tattoos 33, 128
temporalis muscle 1845
Ten Rhijne, William 31
tendinopathy and tendons
introduction 2745
normal function and structure 2757
obesity 2801
periosteal pecking 284
protocols 283
techniques
Achilles tendon 2847
De Quervains stenosing tenosynovitis 2978
golfers elbow 2913
high hamstring tendinopathy 2935
patellar tendinopathy 2957
plantar fasciitis 299300
supraspinatus tendon 2879
tennis elbow 28991
tibialis posterior syndrome 3013
tendon failure 2789
tendon underload 280
use of acupuncture 2813
tennis elbow 28991
tension-type headaches
acupuncture supported by controlled trials 121
evidence for acupunctures effectiveness 11112
NICE recommendations 96, 122
tensor fasciae latae muscle 2201
teres major muscle 16870
teres minor muscle 1667
thoracic and lumbar multifidus muscles 1967
tibialis anterior and posterior muscles 2424
tibialis posterior syndrome 3013
tongue diagnosis 23
traditional Chinese medicine (TCM)
acupuncture as fundamental discipline of 60
alarm 144
basic principles of 201
pulse diagnosis 22
qi 212
tongue diagnosis 23
bioelectromagnetism for correlation with Western medical science 83
channel theory as basis of 78
and diagnostic palpation 1456
dry needling differentiated from 120
holistic practice of 98
within hospitals 28
main disciplines of 1314
need for peaceful coexistence 33
and systems thinking 913
theory
as complex 9
dismissed by Western practitioners 22
every organ has own qi 22
as visceral somatic 145
Western acupuncture evolved from 11
see also acupuncture
trapezius muscles 389, 51, 152, 162, 1867
treatment planning
duration 154
step-by-step guide 1556
strength, and patients sensitivity 154
timing 1545
triceps muscle 1801
trigger points
active 402
affecting motor activity of muscles 142
brachioradialis 21011
dry needling emphasizing concept of 61, 100
examples of disturbances caused by 523
latent 402, 50
multifidus and rotatores 197
palpating 141
pectoralis major 175
sharing some characteristics of acupoints 86
stabilizing function 142
tendency to occur along myofascial meridians 145
in tendon disorders 266, 270, 292, 2945, 303
treating articular dysfunctions 1423
see also myofascial trigger points (MTrPs); individual muscles
tui na 1314, 1516, 19, 25, 78
UK acupuncture organizations 128
unifying theory definition 76
upper trapezius muscle 152, 1867
vasodilators 64, 281, 283
vastus medialis, vastus intermedius and vastus lateralis muscles 1723
visceral dysfunction 1456
visceral fascia 812
visceral pain 51, 53
vitamin deficiencies
consequences of 54
vitamin D 546
vitamins B and C 57
waste disposal 1323
waves
forms 2557
frequency 2535
West
obesity as major health problem 280
patients reacting faster to treatment 149
spread of acupuncture to 312, 96
two approaches to acupuncture 60, 100
Western medical acupuncture see dry needling
Western medicine
acupuncture more accepted by 8, 63, 120
acupuncture standing outside of tradition 103
adoption of techniques, but not concepts 96
bridge with TCM 83
in China 258
continually evolving 11
cultural adaptation 33
dismissal of TCM theory 22, 96
early knowledge of heart 17
fragmentation of fields and specialities 79
inclusion in courses 9
inconclusivity of modern models 867
in Japan 301
move away from reductionism 901
organs 778
perception of deqi 151
recognition of matrix system 7980
standards, research carried out according to 91
workplace recommendations 1289
wrist disorder 2978
wrist extensor muscles 21011
wrist flexor muscles 2069
Xu Xi 1718
Yellow Emperors Canon of Internal Medicine 1415, 60, 78
yin and yang 20, 60
zang fu (organs) 20
Zhi Cong 28
zinc deficiency 56
Author Index
Abate, M. 2801
Abe, H. 126
Ahn, A.C. 60, 978, 246
Aland, C. 78
Alfredson, H. 279, 285
Alimi, D. 112
Allais, G. 112
Amanzio, M. 71
American Physical Therapy Association (APTA) 9
Arendt-Nielsen, L. 252
Arnoczky, S.P. 280
Art and Science of Traditional Medicine, The 91
Aslaksen, P.M. 71
Aubin, A. 140
Baek, Y.H. 252
Baptista, A.S. 101, 108
Bars, D. 68
Bekkering, R. 71
Benarroch, E.E. 63
Benedetti, F. 71
Benharash, P. 846
Bennett, R. 57
Bensoussan, A. 122
Berkoff, G. 38
Berman, B.M. 120, 123
Berry, K. 2534, 2578
Beyens, F. 122
Bing, Z. 68
Birch, S. 30, 78
Blossfeldt, P. 101, 109
BMJ 285
Boewing, G. 111
Borchers, J. 281
Bordelon, P. 54
Bovey, M. 152
Bowsher, D. 60, 63, 66, 1024
Bradnam, L.V. 65, 701
Brinkhaus, B. 107, 112
Bron, C. 36
Buchbinder, R. 109
Butler, D.L. 84
Cagnie, B. 61, 65, 68, 250
Cameron, M.H. 253
Campbell, A. 120
Cannon, W.B. 46, 70
Cao, X. 67
Carla, S. 80
Carlsson, C. 284
Carlton, A.L. 122
Castillo-Gonzlez, F. 288
Chaitow, L. 52, 142
Charvet, B. 277
Chen, W.L. 246, 249
Chen, X.H. 251
Chen, Y.-F. 251
Cheng, R. 249
Cheng, X. 144
Cherkin, D.C. 105, 107
Cheshire, A. 107
Chiu, D. 67, 251
Choi, T.Y. 112
Chou, L.W. 678
Chou, P.C. 134
Christie, D. 46
Chu, H.Y. 134
Chu, J. 66
Chung, J.M. 251
Churchill, D. 845, 148, 1512
Ciccotti, M. 292
Cipolla, M.J. 845, 148, 1512, 277
Clark, B.C. 49
Cook, J. 276, 2789, 282, 285
Cookson, R. 96
Crawford, R. 299
Cummings, M. 124, 150, 258
Curatolo, M. 252
Davies, J. 88
De Almeida, M.D.S. 282
De Freitas, K.M. 282
De Oliveira, L.P. 282
de Souza, M.C. 101, 108
Deadman, P. 18
del Moral, O.M. 10
Denmei, S. 1516, 138, 141, 146
Department of Health 130, 1323
Department of Systems Biology, Harvard Medical School 90
Descarreaux, M. 278, 289
Dharmananda, S. 2456, 258
Dickenson, A.H. 66
Diener, H.C. 111
Dommerholt, J. 8, 10, 36
Dorsher, P.T. 39, 76, 144
Dowling, D. 140
Dubin, J. 299
Eckman, P. 33
Editorial Board of Acupuncture in Medicine 61, 1201
Egerbacher, M. 280
Encong, W. 85
Ergil, K.V. 14
Ernst, E. 109, 123
Ezzo, J. 123
Facco, E. 71
Fahlstrm, M. 285
Felt, R.L. 78
Filshie, J. 150
Finando, D. 76, 78, 92, 138
Finando, S. 76, 78, 92, 138
Findley, T.W. 801
Fine, P.G. 67
Finnoff, J.T. 287
Fixler, M. 29
Flaten, M.A. 71
Foell, J. 101, 104, 113
Foster, N.E. 11011
Franssen, J. 36
Fredericson, M. 293
Freedman, J. 109
Fritz, S. 52
Furlan, A.D. 60, 1067, 123
Gagnon, K. 140
Garrison, F.H. 245
Gerdle, B. 65
Gerwin, R. 36
Ghetu, M. 54
Gildenberg, P.L. 245
Goff, J.G. 299
Goldstein, S.A. 84
Gtzsche, P.C. 101
Government of UK 132, 134
Grant, A. 1345
Green, S. 109
Grbli, C. 10
Guerreiro da Silva, J.B. 8
Guilak, F. 84
Gunn, C.C. 467, 6970, 143, 145
Guo, H.F. 251
Haake, M. 1012, 1045, 107
Hamilton, J.G. 126
Hammerschlag, R. 11, 1024
Han, J.S. 122, 251, 254
Han, S. 122
Han, Z. 251
Hannafin, J.A. 289
Hansson, Y. 284
Hardy, M.L. 10
Hare, B.D. 67
Hasegawa, T.M. 101, 108
Health and Safety Executive (HSE) 1267, 130
Health Protection Agency 128
Hetrick, S. 109
Hill, S. 91
Ho, M.W. 84
Hong, C.Z. 445
Hong, H. 9
Hrbjartsson, A. 101
Hsieh, C.L. 249
Hsu, E. 312
Huang, C. 251, 254
Hubbard, D.R. 38
Huguenin, L.K. 41
Huijing, P. 81
Hurt, J.K. 65
Inoue, M. 106, 282
Jackson, A.O. 8
Jager, H. 82
Janda, V. 138, 142, 145
Jason, A. 1445
Jobe, F. 292
Johnson, M.I. 1012, 105, 113
JOSPT 100
Jrgens, S. 111
Juyi, W. 89
Kalauokalani, D. 105
Kan-Wen Ma 17, 28
Kao, M.J. 678
Kaptchuk, T.J. 978, 121, 124
Kastner, M. 287
Kawakita, K. 60, 250
Kellgren, J.H. 378
Kendall, D.E. 10
Keown, D. 88, 93
Khan, K.M. 275, 277, 2956
Khan, M. 276
Kietrys, D.M. 100
Kim, O. 144
Kim, S.K. 252
Kirby, K.A. 301
Kishmishian, B. 286
Kivity, O. 29
Klingler, W. 82
Knight, D.P. 84
Kobayashi, A. 29
Koes, B.W. 105
Kohls-Gatzoulis, J. 302
Kong, J. 102
Kramer, E.J. 14
Krey, D. 281
Kronfeld, K. 111
Kubo, K. 2812
Kuehn, B.M. 57
Lancerotto, L. 81
Langan, R. 54
Langevin, H.M. 76, 7981, 845, 98, 1445, 148, 1512
Lao, L. 110
LaRiccia, P.J. 122, 249, 2589
Latremoliere, A. 50
Lavagnino, M. 280
Law, P. 249
Le Guellec, D. 277
Leadbetter, W.B. 279
Lederman, J. 54
Lee, B.Y. 122, 249, 2589
Lee, S. 2545, 263
Legge, D. 13940
LeMoon, K. 80
Leung, A. 251
Leung, L. 678, 24950
Lewis, J. 279
Lewith, G. 14, 27
Li, M. 89
Li, W.C. 71
Lianfang, H.E. 249
Liddle, S.D. 107
Lin, J.G. 678, 134, 246, 249, 251
Lin, L.-L. 901
Lindberg, L.G. 65
Linde, K. 105, 11012
Longbottom, J. 279, 281
Longhurst, J. 83, 85
Lucas, K.R. 412
Lund, I. 102, 105
Lundeberg, T. 64, 667, 70, 102, 105, 121, 149
Lyby, P.S. 71
Ma, B.Y. 1345
Maciocia, G. 245, 27
Mackintosh, S.F. 104, 108
MacPherson, H. 98, 1024, 1246, 139, 1489, 258
Madsen, N.V. 101
Maffulli, N. 2767
Maizes, V. 11
Manheimer, E. 110
Mann, F. 139, 284
Mao, J.J. 8, 148
Marchand, A.-A. 278, 289
Marcus, P. 150
Massutato, K. 30
Mathieu, M.-E. 280
Matsumoto, K. 78
Mayer, D.J. 71, 251
Maynard, A. 96
Mayor, D.F. 247, 253, 2557
McCamey, K. 281
McCormack, J. 293
McCreesh, K. 279
McDaid, D. 96
McGechie, D. 77, 80
McKee, M.D. 107
Meeus, M. 63
Melchart, D. 111
Melzack, R. 62, 250
Menses, S. 41
Meridian Acupuncture and Herbal Medicine 100
Milano, R. 67
Milbrandt, W.E. 145
Millan, M.J. 62
Molsberger, A.F. 109
Morin, C. 140
Muller, H.H. 1012, 1045, 107
Murrell, G.A.C. 2745, 278
Myburgh, C. 44
Myers, S.P. 122
Myers, S.S. 105
Myers, T. 79, 144
Nantel, J. 280
Neal, B. 279, 281
Neal, E. 15, 17
Neil-Asher, S. 141, 145
Newberg, A.B. 122, 249, 2589
Ng, A.T. 14
NHS Choices 122
Niemiec, C.J.D. 11
Nijs, J. 63
Noguchi, E. 66
Noordergraaf, A. 245
Nugent-Head, A. 150
Okada, K. 60, 250
Olsson, E. 284
Oostendorp, R.A. 63
Oschman, J. 80, 83
OShaughnessy, J. 278, 289
Ossipov, M.H. 623
Paley, C.A. 112, 251
Papa, J. 297
Paraskevaidis, S. 256
Pariente, J. 712
Park, D.S. 252
Patel, N. 612
Pennick, V. 107
Petersen-Felix, S. 252
Peuker, E.T. 122
Phty, D. 65, 70
Pittler, M.H. 123
Plotnikoff, G.A. 55
Polus, B.I. 412
Pomeranz, B. 67, 120, 249, 251
Price, D.D. 65, 71, 251
Prince, F. 280
Puddu, G. 277
Purdam, C. 2789, 282
Pyne, D. 60, 65, 68, 120, 250
Quigley, J.M. 55
Quinter, J.L. 41
Rafii, A. 71, 251
Rakel, D. 11
Rees, J.D. 274
Rich, P.A. 412
Richards, J. 286
Rickards, L.D. 38
Robertson, J. 15, 146
Rosenblueth, A. 46, 70
Rosenthal, D.S. 112
Ross, J. 109
Royal College of Nursing (RCN) 1267
Ruggiero, F. 277
Rutland, M. 295
Samadelli, M. 33
Sandberg, M. 65, 152
Sato, A. 656
Sato, Y. 656
Schade-Brittinger, C. 1012, 1045, 107
Schaible, H.G. 61, 63
Scharf, H.P. 110
Schleip, R. 80, 824
Schliessbach, J. 68
Schmidt, R.F. 66
Schwartz, I. 66
Scott, A. 274
Selfe, J. 286
Selvanetti, A. 277
Shah, J.P. 45
Shang, C. 869
Sharkey, J. 145
Sharma, P. 2767
Shaw, V. 78
Shen, H. 87
Shenker, N.G. 60, 65, 68, 120, 250
Sherman, K.J. 8, 1045
Silage, D. 245
Silvrio-Lopes, S. 2534
Simons, D.G. 367, 39, 412, 44, 48, 52, 142
Simons, L.S. 36, 52
Speed, C. 274, 282
Stanley, M. 104, 108
Starwynn, D. 86
Staud, R. 63, 65
Stomski, N.J. 104, 108
Streng, A. 105, 111
Stride, M. 274
Stumpf, S.H. 10
Stux, G. 120
Sun, Y. 123
Sussmutt-Dyckorhoff, C. 28
Tague, S.E. 56
Takagi, J. 252
Taylor, S.A. 289
Thomas, K.J. 107
Thomas, S. 105
Tobbackx, Y. 68
Toda, K. 251
Tough, E.A. 123
Travell, J.G. 3641, 48, 52, 142
Trigkilidas, D. 1078
Trinh, K. 109
Tsai, H.-Y. 251
Tse, S.H.M. 14
Tsuchiya, M. 65
Tsuei, J. 77
Uefuji, M. 29
Ulett, G.A. 122
Umlauf, R. 127
van Bussel, R. 71
Van der Wal, J. 82
Van Houdenhove, B. 63
van Tulder, M.W. 105
VanderPloeg, K. 60, 71, 120
Vas, J. 109
Vickers, A.J. 96, 1001, 1034, 108
Villanueva, L. 68
Vincent, C. 125
Wall, P.D. 62, 250
Walsh, S. 2534, 2578
Wang, H.C. 66
Wang, J.-Y. 15, 28, 146
Wang, K.M. 151
Wang, P. 78
Wang Xue Tai 24
Wang, Z.J. 66
Watkin, H. 69
Waumsley, C. 100
Weidong, L. 112
Weiner, R. 46
White, A. 9, 61, 71, 86, 105, 10911, 1201, 1235, 1278, 1501
Wilcox, L. 31
Windridge, D. 77, 83
WISCA 100
Witt, C.M. 105, 107, 10910, 125
Wong, M.-C. 87
Woolf, C. 4950, 52, 247
Woollam, C.H.M. 8
World Health Organization 14, 1212, 125, 127, 134, 259
Wu, M.T. 71
Xie, H.R. 21
Xinghua, B. 24
Xu, Y. 2745, 278
Yamashita, H. 122
Yan, B. 71
Yandow, J.A. 76, 80
Yang, H.I. 252
Yang, J. 257
Yang, J.-W. 90
Yasumo, W. 29
Yi, X. 60, 71, 85, 120
Yonehara, N. 252
Yoo, Y.C. 249, 252
Yu, Y.H. 66
Yuen, J.W.M. 14
Yung, J.Y.K. 14
Zaroff, L. 17
Zhang, G. 120
Zhang, R.X. 254
Zhao, L. 1256
Zhao, Z.-Q. 249, 282
Zhou, W. 846
Zollman, C. 96, 1001, 1034
Zylka, M.J. 65